Ab-0116 - Declaration Of Citizenship (Page 2 of 2) in pdf

_______ Refugees who meet the qualifications set out in 8 U.S.C. 1157

_______ Persons who have been “paroled into the United States,” under 8 U.S.C. 1182(d)(5) or whose deportation

has been withheld under 8 U.S.C. 1253.

_______ Cuban or Haitian entrants as defined by section 501(e) of the Refugee Education Assistance Act of 1980

_______ Persons granted conditional entry into the U.S. under 8 U.S.C. 1153(a)(7) before April 1, 1980, because of

persecution or fear of persecution on account of race, religion, or political opinion or because of being

uprooted by catastrophic national calamity.

_______ An alien who has been “battered” or subjected to “extreme cruelty” by a parent or spouse as defined by 8

U.S.C. 1641(c)(2) and (3), victims’ children, or the parents of children who are victims, may also apply for

license(s) as qualified aliens.

Applicants claiming qualified alien status must submit two (2) or more copies of the following forms, one of which

MUST be a U.S. government issued photo ID, as determined by U.S. Homeland Security to be acceptable for

verification through the SAVE program. Common types of documents used to verify immigration status are:

I-551 (Permanent Resident Card or “Green Card”)

I-766 (Employment Authorization Card)

I-327 (Reentry Permit)

I-571 (Refugee Travel Document)

Machine Readable Immigrant Visa (with Temporary I-551 language)

I-20 (Certificate of Eligibility for Nonimmigrant F91) student status-“student visa”)

DS-2019 (Certificate of Eligibility for Exchange Visitor (J-1) Status)

I-94 (Arrival/Departure Record)

Unexpired Foreign Passport

Unacceptable forms of Identification:

Drivers License

Social Security Cards

Consulate Cards

Applicants claiming status as a non-immigrant shall provide a copy of a machine readable VISA.

_____________________________________________________________________________________________

I affirm under the penalty of perjury that the above is true and correct.

Signed this _____day of ______________, 20 ___.

____________________________________________

Signature

Sworn to before me this _______day of _________________, 20 ___.

AFFIX SEAL HERE

_________________________________________

NOTARY PUBLIC

My Commission Expires: ____________________

If an applicant is discovered to be an unqualified alien, or otherwise ineligible for license(s) under the Act, all license(s) issued to

that applicant must be immediately terminated/void. Anyone who purposefully makes a false, fictitious, or fraudulent claim of

U.S. citizenship or qualified alien status will be liable under the Tennessee False Claims Act. Any person who conspires to

defraud the state or any state governmental entity by securing a false claim allowed or paid to another person in violation of the

Act my be liable under Tennessee’s False Claims Act. Upon discovery of an applicant’s false, fictitious, or fraudulent claim of

U.S. citizenship, state governmental entities must also file a criminal complaint with the United States Attorney.

AB-0116 (rev 5/15)

RDA 2116

Ab-0116 - Declaration Of Citizenship Page 2

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