Form Cf-Es 2058 - Declaration Of United States Citizenship/ Qualified Non-Citizen Status
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DECLARATION OF UNITED STATES CITIZENSHIP/
QUALIFIED NON-CITIZEN STATUS
I certify, under penalty of perjury, by signing my name below, that I am a United States Citizen or that I
have Qualified Non-Citizen Immigration Status. (Adult household members must sign the statement for
members under 18 years of age. In the absence of an adult household member, the applicant may sign
for non-adults.)
ADULT HOUSEHOLD MEMBERS
Check One
Qualified
Name (Print)
Signature
Date
Citizen
Non-Citizen
*
**
Verified by:
INS Form:
*
**
Verified by:
INS Form:
*
**
Verified by:
INS Form:
CHILDREN HOUSEHOLD MEMBERS
Check One
Qualified
Name (Print)
Signature
Date
Citizen
Non-Citizen
*
**
Verified by:
INS Form:
*
**
Verified by:
INS Form:
*
**
Verified by:
INS Form:
*
**
Verified by:
INS Form:
*
**
Verified by:
INS Form:
A copy of the document used to verify US Citizenship of Qualified Non-Citizen Status must be in
the child’s case file, unless the parent or guardian makes the declaration by signing and dating
this form.
* Indicate document used to verify US Citizenship: BC – Birth Certificate; BVS – Birth Verification Screen; BR – Birth
Record/Hospital; BTC – Baptismal Certificate; USP – U.S. Passport;
Other:_______________
** The INS document used to verify Qualified Non-Citizen status must be listed. (Refer to Qualified Non-citizen status
documentation requirements.)
Signature of parent
or legal guardian:________________________________________________ Date:____________
Witness signature if
anyone signs with an “X”:____________________________________________ Date:____________
Authorized Representative’s Name (Print):________________________________________________
Authorized Representative’s Signature:________________________________________________
CF-ES 2058, PDF 09/2005
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