Form Soc 814 - Statement Of Facts Cash Assistance Program For Immigrants (Capi) Page 2
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8IMMIGRANT STATUS
COUNTY USE ONLY
YOU
YOUR SPOUSE
4
a.
Are you a United States citizen?
If yes, go to end of application and sign your name.
YES
NO
YES
NO
b.
Have you or your spouse (or former spouse) ever been in the
YES
NO
YES
NO
U.S. Military Service?
5
a.
Are you lawfully admitted for permanent residence in the
YES
NO
YES
NO
United States?
Resident card on file?
MO.
DAY
YR.
MO.
DAY
YR.
YES
NO
b.
Give the date of lawful admission for permanent residence.
______/______/______
______/______/______
SPONSORED?
c.
Did any person, institution or group sponsor your entry
YES
NO
YES
NO
into the United States? If yes, go to #6. If no, go to #7.
YES
NO
6
a.
Give the following information about your sponsor(s):
AFFIDAVIT OF
SUPPORT
SPONSOR’S NAME
ADDRESS
TELEPHONE NO.
You
(
)
Spouse
Form I-134
SPONSOR’S NAME
ADDRESS
TELEPHONE NO.
You
Form I-864
(
)
Spouse
SPONSOR’S NAME
ADDRESS
TELEPHONE NO.
You
(
)
Spouse
YOU
YOUR SPOUSE
VERIFIED
b.
Is your sponsor deceased?
YES
NO
YES
NO
Deceased
c.
Is your sponsor disabled?
YES
NO
YES
NO
Disabled
d.
Are you being abused by your sponsor or his/her spouse?
Abused
YES
NO
YES
NO
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a.
If not lawfully admitted for permanent residence, briefly explain your current immigration status with the
INS Documentation
Immigration and Naturalization Service (INS):
on file?
YOU
YOUR SPOUSE
Yes
No
YOU
YOUR SPOUSE
b.
Through what date will INS allow you to remain in the
United States? (If indefinitely, indicate.)
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What is your Alien Registration Number?
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What was your Port of Entry?
RESIDENCY
YOU
YOUR SPOUSE
Are you hiding or running from the law for a felony, attempted felony,
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or a parole or probation violation?
YES
NO
YES
NO
If yes, go to the end of the application and sign your name.
U.S. Resident?
Date:
Date:
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a.
When did you first make your home in the United States?
Yes
No
b.
Have you lived outside of the United States since then?
YES
NO
YES
NO
Passport viewed and
From:
From:
c.
Give the dates you were outside of the United States.
copy on file
(month, day, year)
To:
To:
a.
Within 30 days prior to applying for CAPI, were you
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Month aid begins:
YES
NO
YES
NO
outside of the United States?
_____________
Date left:
Date left:
b.
Give the dates you left and returned to the United States.
Date Returned:
Date Returned:
LIVING ARRANGEMENTS
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Check the applicable block to show where you live now:
House
Room (commercial establishment)
Nursing Home
Apartment
Mobile Home
Jail
Room (private home)
Residential Care Facility
Shelter for Battered Women
Hospital
Homeless Shelter
Other Institution
Other (specify) _____________________________
YOUR SPOUSE
YOU
a.
Do you need assistance in your personal care or hygiene,
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IHSS Referral
(e.g., help with eating, dressing, bathing, taking medication,
NMOHC
YES
NO
YES
NO
or moving about)?
Cooking Facilities?
b.
Do you have adequate cooking and food storage facilities
YES
NO
YES
NO
available?
Yes
No
PAGE 2 OF 8
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