Sha-1117 Citiz Form Revision - Seattle Housing Authority
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1
2Address
PO Box 19028
190 Queen Anne Ave N
Seattle, WA 98109-1028
Telephone
206-239-1728
FAX
206-239-1770
1–800–833-6388
TDD
Website
DECLARATION OF CITIZENSHIP OR IMMIGRATION STATUS
Section 214 of the Housing and Community Development Act of 1980, as amended, requires the Seattle Housing Authority (SHA) and the Department of
Housing & Urban Development (HUD) to ensure that financial assistance is made available only to persons who are U.S. Citizensor Non-citizens who
have an eligible immigration status as set forth in 42 U.S.C. Section 1436(a). Please note that not all “legal” statuses are eligible for subsidy.
All adults (18 years and older) in the household must claim their status and sign below. The head of household and/or a responsible adult is required to
certify the status of each minor child in the household. All Non-citizens with a subsidy-eligible status are required to sign a Verification Consent Form
and present their original I-551 Permanent Resident card or I-94 Arrival/Departure record from the Department of Homeland Security in person.
Adult members (18 yrs. and older)
_______________________________________________
Under penalty of perjury, I declare that I am
1.
:
Head of Household (print clearly)
A Citizen of the United States
A Non-Citizen with subsidy-eligible immigration status (check that you have one of the following to verify your status)
I-551 Permanent Resident Card
I-94 Arrival/Departure Record annotated with Section 207, 208, 243(h), or 212(d)(5)
I-94 Arrival/Departure Record and DHS letter or court order granting asylum or withholding of deportation
Not able to certify that I am a U.S. Citizen or a Non-Citizen with a subsidy-eligible immigration status
Signature _____________________________Social Security # (last 4)
Date
_______________________________________________
Under penalty of perjury, I declare that I am
2.
:
Spouse, Co-head, or Other Adult (print clearly)
A Citizen of the United States
A Non-Citizen with subsidy-eligible immigration status (check that you have one of the following to verify your status)
I-551 Permanent Resident Card
I-94 Arrival/Departure Record annotated with Section 207, 208, 243(h), or 212(d)(5)
I-94 Arrival/Departure Record and DHS letter or court order granting asylum or withholding of deportation
Not able to certify that I am a U.S. Citizen or a Non-Citizen with a subsidy-eligible immigration status
Signature _____________________________Social Security # (last 4)
Date
_______________________________________________
Under penalty of perjury, I declare that I am
3.
:
Other Adult (print clearly)
A Citizen of the United States
A Non-Citizen with subsidy-eligible immigration status (check that you have one of the following to verify your status)
I-551 Permanent Resident Card
I-94 Arrival/Departure Record annotated with Section 207, 208, 243(h), or 212(d)(5)
I-94 Arrival/Departure Record and DHS letter or court order granting asylum or withholding of deportation
Not able to certify that I am a U.S. Citizen or a Non-Citizen with a subsidy-eligible immigration status
Signature _____________________________Social Security # (last 4)
Date
____
SHA:
All adults DHS status confirmed:
Yes (See attached DHS print out)
No
Date :
By:
SHA-PL-1117, Rev. 2/14
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