Citizenship Declaration printable pdf download

Citizenship Declaration

CITIZENSHIP DECLARATION

Complete this Declaration for each member of the household.

Last Name ____________________________ First Name ___________________________

Relationship to

Date of

Head of Household _____________________ Sex _________

Birth ________________

Social Security No. ______________________ Alien Registration No. __________________

Admission No. _______________________ if applicable (11-digit number found on DHS

Form-I-94, Departure Record)

Nationality ________________________________ (Foreign nation or country to which you

owe legal allegiance. Normally but not always the country of birth.)

- - - - - - - -

I, ______________________________, SWEAR OR AFFIRM UNDER PENALTY OF

PERJURY UNDER THE LAWS OF THE State of Colorado that (check one):

_____ I am a United States citizen, or

_____ I am a Permanent Resident of the United States, or

_____ I am lawfully present in the United States pursuant to Federal law.

I understand that this sworn statement is required by law because I have applied for a public

benefit. I understand that state law requires me to provide proof that I am lawfully present in

the United States prior to receipt of this public benefit or prior to entering into a contract with

the State.

In order to verify eligible immigration status I am providing the following:

_______

Form I-551, Alien Registration Receipt Card

_______

Form I-94, Arrival-Departure Record with either correct annotation or

accompanied by correct documentation

_______

Form I-688, Temporary Resident Card, annotated “Section 2454A” or

“Section 210.”

Citizenship Declaration