Form In-1806 - Eligibility Verification For Entitlements Act Attestation printable pdf download

Form In-1806 - Eligibility Verification For Entitlements Act Attestation

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ADMINISTRATIVE SERVICES DIVISION

PERMITS AND LICENSES UNIT

500 JAMES ROBERTSON PARKWAY

NASHVILLE, TENNESSEE 37243

Eligibility Verification for Entitlements Act Attestation Instructions

INSTRUCTIONS: If you are a natural person applying for a license, registration, certification or other benefit

you must:

1. Attest, under penalty of perjury, to your status as either a United States citizen, a qualified alien as

defined in Tennessee’s Eligibility Verification for Entitlements Act, or a foreign national not physically

present in the United States, by selecting your status in Part A below signing on the line labeled

“Applicant’s Signature,” printing your name on the line labeled “Printed Name” and putting the current

date on the line labeled “Date.”

AND

Do one (1) of the following:

If you are claiming United States citizenship, present one (1) of the forms of identification provided for

in Part B below. If you provided your Social Security Number as part of your application for

licensure, registration, certificate or other benefit, no additional documentation is required;

however, please be aware that efforts may be made to verify any such number.

If you are claiming qualified alien status, you MUST present two (2) forms of documentation (front and

back) of identity and immigration status, as determined by the United States Department of Homeland

Security to be acceptable for verification through the SAVE program, as provided in Part C below.

(Failure to provide two forms of documentation as described will result in a delay to determining

eligibility for licensure.)

If you are claiming qualified alien status but you are unable

to present two (2) forms of documentation

provided for in Part C of this form, then you shall present at least one (1) such document that shall then

be verified through the SAVE program.

5. If you are claiming you are foreign national not physically present in the United States, contact the

program issuing the license, registration, certification or other benefit for which you are applying to

provide such documentation as may be required to verify such status.

IN-1806 (Rev. 07/14) (V. 03/16)

RDA

Form In-1806 - Eligibility Verification For Entitlements Act Attestation