Affidavit Of Immigration Status Form - Colorado Department Of Labor & Employment
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1Colorado Department of Labor & Employment
Workforce Development Programs
AFFIDAVIT OF IMMIGRATION STATUS
Print Your Name:
Social Security Number:
Are you a United States (U.S.) citizen?
Yes
No
If No, verify or provide your alien permit number.
Alien Permit Number
If you are not a U.S. citizen, are you in satisfactory immigration status?
Yes
No
In accordance with the Colorado Revised Statutes 24-76.5, you must possess one of the following forms of identification (ID).
Check the appropriate box and provide the ID number and the expiration date, if any. If you do not possess one of the forms
of ID listed and do not provide the requested information, your benefits may be denied.
Colorado Driver's License
Colorado Identification Card
ID Number
ID Number
Expiration Date
Expiration Date
U.S. Military Card
Military Dependent Identification Card
ID Number
ID Number
Expiration Date
Expiration Date
U.S. Coast Guard Merchant Mariner Card
Native American Tribal Document
ID Number
ID Number
Expiration Date
Expiration Date
Other State Driver's License/State ID Card
U.S. Passport
ID Number
ID Number
Expiration Date
Expiration Date
Affirmation
I affirm under penalty of perjury that the above information is true to the best of my knowledge. I understand that my lawful
presence in the U.S. will be verified before workforce program services can be provided. I affirm that I am a U.S. citizen, legal
permanent resident, or am otherwise lawfully present in the U.S. I understand that there are severe penalties for providing
false statements and willfully misrepresenting information in order to obtain or increase workforce program services. I
authorize the release of all information to determine my eligibility for workforce program services. I understand this may
include release of information from former employers, verification with the U.S. Bureau of Citizenship and Immigration
Services, and sharing of information with other public agencies in the performance of their public duties in accordance with
the Colorado Employment Security Act 8-72-107.
Signature
Date
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