Hcd Benefits Status Form 1 - Statement Of Citizenship, Alienage, And Immigration Status For State Public Benefits
Download a blank fillable Hcd Benefits Status Form 1 - Statement Of Citizenship, Alienage, And Immigration Status For State Public Benefits in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Hcd Benefits Status Form 1 - Statement Of Citizenship, Alienage, And Immigration Status For State Public Benefits with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2STATE OF CALIFORNIA -BUSINESS, TRANSPORTATION AND HOUSING AGENCY
DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT
STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS
FOR
STATE PUBLIC BENEFITS
Print Name of Applicant (Applicant is the person who wants a license, certificate, approval or permit to operate)
Date
Print Name of Person Acting for Applicant, if any
Relationship to Applicant
Type of Application (check all that apply)
Type of Application (check all that apply)
MANUFACTURER LICENSE
COURSE PROVIDER APPROVAL
DEALER LICENSE
INSTRUCTOR APPROVAL
SALESPERSON LICENSE
THIRD-PARTY AGENCY APPROVAL
90-DAY CERTIFICATE
QUALITY ASSURANCE INSPECTOR APPROVAL
PERMIT TO OPERATE MOBILEHOME PARK
PERMIT TO OPERATE EMPLOYEE HOUSING
CITIZENSHIP/IMMIGRATION STATUS DECLARATION
Citizens and nationals of the United States who meet all eligibility requirements may receive Occupational Licenses, Certificates,
Approvals and/or Permits to Operate and must fill out SECTIONS A and D.
Aliens who meet all eligibility requirements may also receive Occupational Licenses, Certificates, Approvals and/or Permits to Operate
and must complete SECTIONS A, B, and D, and if necessary, SECTION C of this form.
SECTION A: CITIZENSHIP/IMMIGRATION STATUS DECLARATION
1. Are you a citizen or national of the United States?
Yes
No
If the answer to the above question is yes, where were you born? ______________________________________________
(City/State/Country)
2.
To establish citizenship or nationality, please submit a legible and unaltered copy of one of the documents on LIST A.
IF YOU ARE A CITIZEN OR NATIONAL OF THE UNITED STATES, GO DIRECTLY TO SECTION D. IF YOU ARE AN ALIEN,
PLEASE COMPLETE SECTION B, AND, IF NECESSARY, SECTION C.
SECTION B: ALIEN STATUS DECLARATION
IMPORTANT: Please indicate your alien status below, and submit documents evidencing such status. The alien status documents listed
for each category are the most commonly used documents that the United States Immigration and Naturalization Service (INS) provide to
aliens in those categories. You can provide other acceptable evidence of your alien status even if not listed below.
An alien lawfully admitted for permanent residence under the Immigration and Naturalization Act (INA). Evidence includes:
•
INS Form 1-551 (Alien Registration Receipt Card, commonly known as a “green card”); or
•
Unexpired Temporary 1-551 stamp in foreign passport or on INS Form 1-94.
An alien who is granted asylum under section 208 of the INA. Evidence includes:
•
INS Form 1-94 annotated with stamp showing grant of asylum under section 208 of the INA;
•
INS Form 1-688B (Employment Authorization Card annotated “274a.12(a)(5)”.
•
INS Form 1-766 (Employment Authorization Document) annotated “A5”.
•
Grant letter from the Asylum Office of INS; or
•
Order of an immigration judge granting asylum.
A refugee admitted to the United States under section 207 of the INA. Evidence includes:
•
INS Form I-94 annotated with stamp showing admission under s207 of the INA;
•
INS Form I-688B (Employment Authorization Card) annotated “274a.12(a)(3)”.
HCD Benefits Status Form 1 (Rev 8/98)
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 250.61 - Statement Of Citizenship, Alienage, And Immigration Status For Application Of Department Of Corporations License Or Certificate
Legal
Form Ftb 9225 C-1 - Declaration Of Citizenship, Alienage, And Immigration Status For Homeowner And Renter Assistance
Financial
Form 13325 - Statement Of Assurance Concerning Civil Rights Compliance For Irs Spec Partnerships
Financial
Related Categories
Parent category: Legal