Form Abl-920 - Verification Of Lawful Presence In The United States -- Applicant And Principals
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1
21350
STATE OF SOUTH CAROLINA
ABL-920
DEPARTMENT OF REVENUE
(Rev. 5/13/13)
VERIFICATION OF LAWFUL PRESENCE IN THE
4382
UNITED STATES -- APPLICANT AND PRINCIPALS
STATE OF
FOR INTERNAL USE ONLY
)
)
Case Verification Number
COUNTY OF
)
Result
Pursuant to the provisions of S.C. Code Ann. Section 8-29-10, et seq. of the South Carolina Illegal Immigration
Reform Act and Title 61 of South Carolina Code Ann. Sections, every principal that is an individual must submit the
following information:
The undersigned
of
,
(Home Address)
(Print clearly First, Middle and Last name)
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.
I am a Foreign Citizen, and resident of
(Country of Residency)
and reside at
,
(Street Address)
(City, State, and Zip Code)
Other (Explain):
Date of Birth
Alien Registration Number
(MUST ATTACH COPY OF IMMIGRATION DOCUMENTS)
I UNDERSTAND AND ACKNOWLEDGE that any person who fails to execute this Affidavit will automatically be denied the license
to which it applies; and further, that the representations made in this Affidavit shall apply throughout any license(s) or renewals
issued; and further, that I shall have an affirmative duty to immediately advise the Department of Revenue in any change of my
immigration or citizenship status. I, hereby, also 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).
Under penalty of perjury and recognizing that I am subject to the criminal and civil penalties imposed by Title 12, of the
South Carolina Code of Laws, I declare that I have examined this Affidavit and to the best of my knowledge and belief, it
is true, correct and complete.
REQUIRED: Fill out completely.
Signature of Affiant
License Number:
SWORN to and subscribed before me this
day of
, year of
Business Name:
Notary Public for
My Commission Expires:
Contact Person:
(Name)
Notary (L.S.)
(
)
Contact Person Phone Number:
Notary (printed name)
43821024
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