Application For A Child Care Center License Form - Dhhs Page 5
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7LEGAL ATTESTATION
THIS PAGE TO BE COMPLETED ONLY IF THE PROGRAM IS OWNED BY AN INDIVIDUAL OR PARTNERSHIP
INDIVIDUAL OWNER/PARTNER #1
Legal Name:_______________________________Social Security Number:_________________________
Check one: __a. I am a citizen of the United States; OR
__b. I am qualified alien under the Federal Immigration and Nationality Act. My
Immigrant status and alien number is:____________________________________
If you checked box b above you must check the box of the document you are providing to verify
your lawful presence in the United States:
__An Alien Registration Receipt Card (Form I-551, otherwise known as a “Green Card”)
__An unexpired foreign passport with an unexpired Temporary I-551 Stamp bearing the same
name as the passport
__A document showing an Alien Registration Number (A#)
__A form I-94 (Arrival-Departure Record)
Signature: _______________________________________________________________ Date:__________________________
INDIVIDUAL OWNER/PARTNER #2
Legal Name:_______________________________Social Security Number:_________________________
Check one: __a. I am a citizen of the United States; OR
__b. I am qualified alien under the Federal Immigration and Nationality Act. My
Immigrant status and alien number is:____________________________________
If you checked box b above you must check the box of the document you are providing to verify
your lawful presence in the United States:
__An Alien Registration Receipt Card (Form I-551, otherwise known as a “Green Card”)
__An unexpired foreign passport with an unexpired Temporary I-551 Stamp bearing the same
name as the passport
__A document showing an Alien Registration Number (A#)
__A form I-94 (Arrival-Departure Record)
Signature:_ _______________________________________________________________ Date:_______________________
INDIVIDUAL OWNER/PARTNER #3
Legal Name:_______________________________Social Security Number:_________________________
Check one: __a. I am a citizen of the United States; OR
__b. I am qualified alien under the Federal Immigration and Nationality Act. My
Immigrant status and alien number is:_____________________________________________________
If you checked box b above you must check the box of the document you are providing to verify
your lawful presence in the United States:
__An Alien Registration Receipt Card (Form I-551, otherwise known as a “Green Card”)
__An unexpired foreign passport with an unexpired Temporary I-551 Stamp bearing the same
name as the passport
__A document showing an Alien Registration Number (A#)
__A form I-94 (Arrival-Departure Record)
Signature: _______________________________________________________________Date:_______________________
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