Citizenship Immigration Status Verification Form printable pdf download

Citizenship/Immigration Status Verification

DPI-CISV (Rev 05/11)

Instructions

Why are we asking for your citizenship/immigration status?

All state agencies are required to verify the lawful presence in the United States of all natural persons (individuals and individuals doing business as sole

proprietors) who apply for certain public benefits, including the license, permit or registration for which you are applying.

(Colorado Revised Statutes section 24-76.5-103)

Who does this apply to?

This requirement applies only to natural persons as described above. It does NOT apply to partnerships, corporations or other business entities that apply for state benefits.

How do I complete this form?

If you are applying for a license, permit or registration for yourself, or for a business for which you are the sole proprietor, you must provide the information

requested in numbered paragraphs 1 through 4 on this form, sign and date it, and submit it along with your application form for the license you are applying for.

What form of identification do I need to provide with this form?

You are required to provide one of the following;

Colorado driver’s license number

Electronic Identification Indicator (“EII”)

OR one of the following alternative identification documents:

Driver’s license or identification card issued by;

Alabama

District of Columbia

Kansas

Minnesota

New Jersey

Pennsylvania

Virginia

Alaska

Florida

Kentucky

Mississippi

New York

Rhode Island

West Virginia

Arizona

Georgia

Louisiana

Missouri

North Carolina

South Carolina

Wisconsin

Arkansas

Hawaii

Maine

Montana

North Dakota

South Dakota

Wyoming

California

Idaho

Maryland

Nebraska

Ohio

Tennessee

Connecticut

Indiana

Massachusetts

Nevada

Oklahoma

Texas

Delaware

Iowa

Michigan

New Hampshire

Oregon

Vermont

OR a valid:

Colorado ID card

U.S. Military ID card

Military Dependent’s Card

U.S. Coast Guard Merchant Mariner Card

Native American tribal identification document;

U.S. naturalization certificate with photograph

U.S. Passport or other citizenship document with photograph

OR valid immigration documents demonstrating lawful presence:

Foreign passport with I-551 stamp or attached Temporary I-551 visa

Foreign passport accompanied by an I-94 indicating expiration date

I-94 with refugee or asylum status

Resident Alien card

Permanent Resident card

Temporary Resident card

Employment Authorization card

If you do not have any of the above forms of identification, you must apply for an EII from the Colorado Division of Motor Vehicles (“DMV”) before completing this

form. Information on obtaining an EII is available at the DMV website:

Citizenship/Immigration Status verification

1. Print name of individual/sole proprietor:

________________________________________________________________________________________

2. Business name, if different:

________________________________________________________________________________________

3. a) Colorado driver’s license number:

________________________ or b) Electronic Identification Indicator (“EII”): ________________________

or c) Alternative Identification Document:

________________________ (Describe and attach notarized copy if not applying in person)

4. I swear and affirm under penalty of perjury under the laws of the State of Colorado that the information I have provided on this form is complete and

accurate and (check one):

A) ___ I am a United States citizen

Alien number

OR I-94 number

AND Date of Birth

B) ___ I am a permanent resident of the United States

________________

_______________

___________

C) ___ I am lawfully present in the United States pursuant to Federal law

________________

_______________

___________

IF YOU CHECk B OR C PROvIDE A COPY OF THE CERTIFICATE/CARD THAT DOCUmENTS lAWFUl PRESENCE IN THE U.S.

and I understand that this sworn statement is required by law because I have applied for a public benefit that is subject to Colorado Revised Statutes section

24-76.5-103. I understand that this state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit.

I understand that if I am not a United States citizen this law requires the Colorado Department of Agriculture (“CDA”) to verify my lawful presence in the United

States through the federal Department of Homeland Security (“DHS”) Citizenship and Immigration Services (“CIS”) Systematic Alien Verification of Entitlement

Program. I hereby authorize DHS/CIS to provide CDA with information related to my immigration status. I further acknowledge that making a false, fictitious, or

fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado

Revised Statute section 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.

Applicant Signature: _____________________________________________________________ Date: _________________________________________