Application For Luther House Apartment Template Page 8
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14_____ Block 1. a citizen or national of the United States. (If you check this block, no
further information is required. Sign and date below and forward this form to the
name and address specified in the attached notification. If this block is checked on
behalf of a child, the adult who resides in the assisted unit and who is responsible for
the child should sign and date below).
_________________________________________
_____________________
Signature
Date
_____ Block 2. a non-citizen with eligible immigration status in the category checked
below:
_____(i) A non-citizen lawfully admitted for permanent residence, as defined by
section 101(a) (20) of the Immigration and Nationality Act (INA) as an
immigrant, as defined by section 101 (a) (15), of the INA (8 U.S.C.
1001 (a) (20) and 1101 (a) (15), respectively) (immigrants) (This
category includes a non-citizen admitted under section 210 or 210 A of
the INA (8 U.S.C. 1160 or 1161), (special agricultural worker), who
has been granted lawful resident status;
_____(ii) A non-citizen who entered the United States before January 1, 1972, or
such later date as enacted by law, and has continuously maintained
residence in the United States since then, and who is not eligible for
citizenship, but who is deemed to be lawfully admitted for permanent
residence as a result of an exercise of discretion by the Attorney
General under section 249 of the INA (8 U.S.C. 1259).
_____(iii) A non-citizen who is lawfully present in the United States pursuant to
an admission under section 207 of the INA (8 U.S.C. 1157) (refugee
status); pursuant to the granting of asylum (which has not been
terminated) under section 208 of the INA (8 U.S.C. 1158) (asylum
status); or as a result of being granted conditional entry under section
203 (a)(7) of the INA (8 U.S.C. 1153 (a)(7)) before April 1, 1980,
because of persecution or fear of persecution because of race, religion,
or political opinion or because of being uprooted by catastrophic
national calamity;
_____(iv) A non-citizen who is lawfully present in the United States as a result of
an exercise of discretion by the Attorney General for emergent reasons
or reasons deemed strictly in the public interest under section
212(d)(5) of the INA (8 U.S.C. 1182(d)(5)) (parole status);
_____(v) A non-citizen who is lawfully present in the United States as a result of
the Attorney General’s withholding deportation under section 243 (h)
of the INA (8 U.S.C. 1253 (h)) (threat to life or freedom); or
______(vi) A non-citizen lawfully admitted for temporary or permanent residence
under section 245A of the INA (8 U.S.C. 1255a) (amnesty granted
under INA 245A).
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