Form In-1806 - Eligibility Verification For Entitlements Act Attestation (Page 2 of 3) in pdf

Page 2 of 3

Eligibility Verification for Entitlements Act Attestation

Part A. Eligibility Verification for Entitlements Act Attestation

I hereby attest under penalty of perjury that I am (select one):

____

A United States citizen;

____

A qualified alien as defined in Tenn. Code Ann. § 4-58-102;

Driver’s license and Social Security card are not acceptable documentation under part C below.

____

A foreign national not physically present in the United States. Further, I understand that should I ever

become physically present in the United States while I hold this license, registration, certification or

other benefit I agree to immediately contact the issuing agency and provide documentation to confirm

my status as a qualified alien.

_________________________________

Applicant’s Signature

_________________________________

Printed Name

Date

Submitting false information or omitting pertinent or material information in connection with this

application or any violation of the Eligibility Verification for Entitlements Act may result in the

revocation of any license, registration, certification or other benefit issued to the applicant. A person who

willfully makes a false, fictitious or fraudulent statement or representation of United States citizenship

may be prosecuted under 18 U.S.C. § 911 and/or the False Claims Act, T.C.A. §§ 4-18-101, et seq.

Qualified alien means “A qualified alien as defined by 8 U.S.C. § 1641(b)” or “An alien or nonimmigrant eligible to receive state or local public benefits

under 8 U.S.C. § 1621(a).” Pursuant to those statutes, this includes, but is not necessarily limited to:

•

An alien who is lawfully admitted for permanent residence under the Immigration and Nationality Act [8 U.S.C. § 1101 et seq.];

•

An alien who is granted asylum under section 208 of the Immigration and Nationality Act [8 U.S.C. § 1158];

•

A refugee who is admitted to the United States under section 207 of the Immigration and Nationality Act [8 U.S.C.A. § 1157];

•

An alien who is paroled into the United States under section 212(d)(5) of the Immigration and Nationality Act [8 U.S.C. § 1182(d)(5)] for a

period of at least 1 year;

•

An alien whose deportation is being withheld under section 243(h) of the Immigration and Nationality Act [8 U.S.C. § 1253] (as in effect

immediately before the effective date of section 307 of division C of Public Law 104-208) or section 241(b)(3) of the Immigration and

Nationality Act [8 U.S.C. § 1231(b)(3)] (as amended by section 305(a) of division C of Public Law 104-208);

•

An alien who is granted conditional entry pursuant to section 203(a)(7) of the Immigration and Nationality Act [8 U.S.C. § 1153(a)(7)] as in

effect prior to April 1, 1980;

•

An alien who is a Cuban and Haitian entrant (as defined in section 501(e) of the Refugee Education Assistance Act of 1980);

•

A nonimmigrant under the Immigration and Nationality Act [8 U.S.C. §§ 1101, et seq.];

•

An alien who is paroled into the United States under section 212(d)(5) of the Immigration and Nationality Act [8 U.S.C. § 1182 (d)(5)] for less

than one year.

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

RDA 10222

Form In-1806 - Eligibility Verification For Entitlements Act Attestation Page 2

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