Form Fa-001 - Application For Benefits (Page 13 of 31) in pdf

Do you need help with this application? Visit

or call 1-855-HEA-PLUS (432-7587).

Is PERSON 3 a U.S. citizen or U.S. national? See page D for more information.

 Yes  No

 Choose not to answer

If PERSON 3 is NOT a U.S. citizen, what is his/her immigration status?

 Lawful Permanent Resident (LPR)

 Battered Spouse, Child or Parent

 Removal/Suspension of Deportation

 Lawful Temporary Resident

 Cuban-Haitian Entrant

 Registry Applicants

 Non-Immigrant Status

 Deferred Action Status

 Special Immigrant Juvenile Status Applicant

 Asylee

 Deferred Enforced Departure

 Temporary Protection Status (TPS)

 Refugee

 Legalization under LIFE Act

 Victim of Trafficking

 Conditional Entrant granted before 1980

 Legalization under IRCA Applicant

 Withholding of Deportation

 Other

 Order of Supervision

 Applicant for Asylum, LPR, TPS, or

 I do not want to provide

 Paroled into United States

Withholding Deportation

What immigration document does PERSON 3 have?

Immigration Document Number: ________________________________

 Permanent Resident card

 I-94

 Visa

Has PERSON 3 lived in the U.S. since August 22, 1996?  Yes  No

 Foreign Passport

 None

 Other: _______________________________

Is PERSON 4 a U.S. citizen or U.S. national? See page D for more information.

 Yes  No

 Choose not to answer

If PERSON 4 is NOT a U.S. citizen, what is his/her immigration status?

 Lawful Permanent Resident (LPR)

 Battered Spouse, Child or Parent

 Removal/Suspension of Deportation

 Lawful Temporary Resident

 Cuban-Haitian Entrant

 Registry Applicants

 Non-Immigrant Status

 Deferred Action Status

 Special Immigrant Juvenile Status Applicant

 Asylee

 Deferred Enforced Departure

 Temporary Protection Status (TPS)

 Refugee

 Legalization under LIFE Act

 Victim of Trafficking

 Conditional Entrant granted before 1980

 Legalization under IRCA Applicant

 Withholding of Deportation

 Other

 Order of Supervision

 Applicant for Asylum, LPR, TPS, or

 I do not want to provide

 Paroled into United States

Withholding Deportation

What immigration document does PERSON 4 have?

Immigration Document Number: ______________________________

 Permanent Resident card

 I-94

 Visa

Has PERSON 4 lived in the U.S. since August 22, 1996?  Yes 

 Foreign Passport

 None

 Other: ____________________________

Is PERSON 5 a U.S. citizen or U.S. national? See page D for more information.

 Yes

 No

 Choose not to answer

If PERSON 5 is NOT a U.S. citizen, what is his/her immigration status?

 Lawful Permanent Resident (LPR)

 Battered Spouse, Child or Parent

 Removal/Suspension of Deportation

 Lawful Temporary Resident

 Cuban-Haitian Entrant

 Registry Applicants

 Non-Immigrant Status

 Deferred Action Status

 Special Immigrant Juvenile Status Applicant

 Asylee

 Deferred Enforced Departure

 Temporary Protection Status (TPS)

 Refugee

 Legalization under LIFE Act

 Victim of Trafficking

 Conditional Entrant granted before 1980

 Legalization under IRCA Applicant

 Withholding of Deportation

 Other

 Order of Supervision

 Applicant for Asylum, LPR, TPS, or

 I do not want to provide

 Paroled into United States

Withholding Deportation

What immigration document does PERSON 5 have?

Immigration Document Number: _________________________________

 Permanent Resident card

 I-94

 Visa

Has PERSON 5 lived in the U.S. since August 22, 1996?  Yes  No

 Foreign Passport

 None

 Other: ______________________________

Is PERSON 6 a U.S. citizen or U.S. national? See page D for more information.

 Yes  No

 Choose not to answer

If PERSON 6 is NOT a U.S. citizen, what is his/her immigration status?

 Lawful Permanent Resident (LPR)

 Battered Spouse, Child or Parent

 Removal/Suspension of Deportation

 Lawful Temporary Resident

 Cuban-Haitian Entrant

 Registry Applicants

 Non-Immigrant Status

 Deferred Action Status

 Special Immigrant Juvenile Status Applicant

 Asylee

 Deferred Enforced Departure

 Temporary Protection Status (TPS)

 Refugee

 Legalization under LIFE Act

 Victim of Trafficking

 Conditional Entrant granted before 1980

 Legalization under IRCA Applicant

 Withholding of Deportation

 Other

 Order of Supervision

 Applicant for Asylum, LPR, TPS, or

 I do not want to provide

 Paroled into United States

Withholding Deportation

What immigration document does PERSON 6 have?

Immigration Document Number: ________________________________

 Permanent Resident card

 I-94

 Visa

Has PERSON 6 lived in the U.S. since August 22, 1996?  Yes  No

 Foreign Passport

 None

 Other: _____________________________

FA-001 (12-17)

Page

Form Fa-001 - Application For Benefits Page 13

Related Articles

Related forms

Related Categories