Form L-3003 - Verification Of Lawful Presence In The United States
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1
21350
1350
STATE OF SOUTH CAROLINA
L-3003
DEPARTMENT OF REVENUE
(Rev. 9/29/08)
VERIFICATION OF LAWFUL PRESENCE
4381
IN THE UNITED STATES
FOR INTERNAL USE ONLY
)
STATE OF SOUTH CAROLINA
)
Case Verification Number
)
COUNTY OF
Result
Pursuant to the provisions of the South Carolina Illegal Immigration Reform Act, S.C. Code Ann. Section 8-29-10, et
seq., every agency of this State shall verify the lawful presence in the United States of any alien 18 years of age or
older who has applied for state or local public benefits.
The undersigned
of
,
(Print clearly First, Middle and Last name)
(Home Address)
being first duly sworn deposes and states as follows:
(City, State and Zip Code)
Name Change/ Alias:
Yes
No
If yes, please list:
Check ONLY One Box: See reverse side for Instructions, Definitions, and Accepted Documents.
I am a United States Citizen eighteen years of age or older.
I am a Legal Permanent Resident eighteen years of age or older.
I am a Qualified Alien under the Federal Immigration and Nationality Act, Public Law 82-44, eighteen years
of age or older, and lawfully present in the United States.
Other (Explain):
Date of Birth
Alien Registration Number
(MUST ATTACH COPY OF IMMIGRATION DOCUMENTS)
I UNDERSTAND AND ACKNOWLEDGE that a person who knowingly and willfully makes a false, fictitious, or fraudulent
statement or representation in an affidavit executed pursuant to South Carolina Code Section 8-29-10 entitled Verification of
Lawful Presence shall in addition to other sanctions imposed by this state or the United States, be guilty of a felony and upon
conviction must be fined and/or imprisoned for not more than 5 years (or both).
I UNDERSTAND AND ACKNOWLEDGE that any person who fails to execute this Affidavit will automatically be denied the license
to which it applies. That further, the representations made in this Affidavit shall continue throughout the license period and any
subsequent renewals; and I understand and agree to notify the Department of any change of my legal status as a U.S. citizen,
legal permanent resident or alien lawfully present in the United States.
Under of penalty of perjury, I hereby declare that I have examined this Affidavit and to the best of my knowledge and
belief, it is true, correct and complete.
Signature of Affiant
REQUIRED: Fill out completely.
SWORN to and subscribed before me this
License Number:
day of
, year of
Notary Public for
Business Name:
My Commission Expires:
Contact Person:
Notary (L.S.)
(Name)
Notary (printed name)
(
)
Contact Person Phone Number:
43811025
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