Hcd Benefits Status Form 1 - Statement Of Citizenship, Alienage, And Immigration Status For State Public Benefits Page 2
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INS Form I-766 (Employment Authorization Document) annotated “A3”; or
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INS Form 1-571 (Refugee Travel Document).
An alien paroled into the United States for at least one year under section 212(d)(5) of the INA. Evidence includes:
•
INS Form I-94 with stamp showing admission for at least one year under section 212(d)(5) of the INA. (Applicant cannot
aggregate periods of admission for less than one year to meet the one-year requirement.)
An alien whose deportation is being withheld under section 243(h) of the INA (as in effect immediately prior to September 30,
1996) of Section 241(b)(3) of such Act (as amended by section 305(a) of division C of Public Law 104-208). Evidence includes:
•
INS Form 1-688B (Employment Authorization Card) annotated “247a. 12(a)(10)”.
•
INS Form 1-766 (Employment Authorization Document) annotated “A10”; or
•
Order form an immigration judge showing deportation withheld under s 243(h) of the INA as in effect prior to April 1,
1997, or removal withheld under s 241(b)(3) of the INA.
An alien who is granted conditional entry under section 203(a)(7) of the INA as in effect prior to April 1, 1980. Evidence
includes:
•
INS Form 1-94 with stamp showing admission under s203(a)(7) of the INA;
•
INS Form 1-688B (Employment Authorization Card) annotated “274a. 12(a)(3)”; or
•
INS Form I-766 (Employment Authorization Document) annotated “A3.”
An alien who is a Cuban and Haitian entrant (as defined in section 501(e) of the Refugee Education Assistance Act of 1980).
Evidence includes:
•
INS Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”) with the code CU6, CU7, or CH6:
•
Unexpired temporary I-551 stamp in foreign passport or on INS Form I-94 with the code CU6 or CU7; or
•
INS Form I-94 with stamp showing parole as “Cuba/Haitian Entrant” under Section 212(d)(5) of the INA.
An alien paroled into the United States for less than one year under section 212(d)(5) of the INA. (Evidence includes INS Form
1-94 showing this status.)
An alien not in categories 1 through 8 who has been admitted to the United States for a limited period of time (a non-immigrant).
Non-immigrants are persons who have temporary status for a specific purpose.
(Evidence includes INS Form I-94 showing this status.)
SECTION C: DECLARATION FOR BATTERED ALIENS
IMPORTANT: Complete this section if the applicant, the applicant’s child or the applicant child’s parent has been battered or subjected
to extreme cruelty in the United States.
Has the INS or the EOIR granted a petition or application filed by or on behalf of the applicant, the applicant’s child, or the
applicant child’s parent under the INA or found that a pending petition sets forth a prima facie case? Evidence includes one of
the documents on List B (attached hereto).
Has the applicant, the applicant’s child, or the applicant child’s parent has been battered or subjected to extreme cruelty in the
United States by a spouse or parent, or by a spouse’s or parent’s family member living in the same house (where the spouse or
parent consented to, or acquiesced in the battery or cruelty)?
SECTION D: DECLARATION
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE
ANSWERS I HAVE GIVEN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Applicant’s Signature: ______________________________________________ Date: ______________________
Signature of Person
Acting For Applicant:
______________________________________________ Date: ______________________
HCD Benefits Status Form 1 (Rev 8/98)
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