Declaration Of Section 214 Status
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1
2DECLARATION OF SECTION 214 STATUS
Notice to applicants and tenants: In order to be eligible to receive the housing sought, each applicant for, or
recipient of, housing assistance must be lawfully within the U.S. Please read the Declaration statement carefully
and sign and return to the Montana Department of Commerce, Local Field Agent Office. Please feel free to
consult with an immigration lawyer or other immigration expert of your choosing.
1
I, _________________________________________________________ certify, under penalty of perjury
, that, to the best
of my knowledge, I am lawfully within the United States because (please check the appropriate box):
£ I am a citizen by birth, a naturalized citizen or a national of the United States; or
2
£ I have eligible immigration status and I am 62 years of age or older. Attach evidence of proof of age
; or
£ I have eligible immigration status as checked below (see reverse side of this form for explanations). Attach INS
document(s) evidencing eligible immigration status and signed verification consent form.
3
£ Immigrant status under §§101(a)(15) or 101(a)(20) of the Immigration and Nationality Act (INA)
;or
4
£ Permanent residence under §249 of INA
; or
5
£ Refugee, asylum, or conditional entry status under §§207, 208, or 203 of the INA
; or
6
£ Parole status under
§§212(d)(5) of the INA
; or
7
£ Threat to life or freedom under §243(h) of the INA
; or
8
£ Amnesty under §245A of the INA
.
________________________________________________________
______________________
(Signature of Family Member)
(Date)
£
Check box on left if signature is of adult residing in the unit who is responsible for child named on statement above.
HA: Enter INS/SAVE Primary Verification #:______________________________________ Date:____________________
(See reverse side for footnotes and instructions.)
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