1. Warning: 18 U.S. C. 1001 provides, among other things, that whoever knowingly and willfully makes or uses a document or writing containing any false, fictitious, or fraudulent statement or entry, in any manner within the jurisdiction of any department of agency of the United States, shall be fined not more than $10,000 or imprisoned for not more than five years, or both.
The following footnotes pertain to noncitizens who declare eligible immigration status in one of the following categories:
2. Eligible immigration status and 62 years of age or older. For noncitizens who are 62 years of age or older or who will be 62 years of age or older and receiving assistance under a Section 214 covered program on June 19, 1995. If you are eligible and elect to select this category, you must include a document providing evidence of proof of age. No further documentation of eligible immigration status is required.
3. Immigrant status under ¶101(a)(15 or 101(a)(20) of INA. A noncitizen lawfully admitted for permanent residence, as defined by ¶101(a)(20) of the Immigration and Nationality Act (INA), as an immigrant, as defined by ¶101(a)(15) of the INA (8 U.S.C. 1101 (a)(15), respectively [immigrant status]. This category includes a noncitizen admitted under ¶210 or 210A of the INA (8 U.S.C. 1160 or 1161), [special agricultural worker status], who has been granted lawful temporary resident status.
4. Permanent residence under ¶249 of INA. A noncitizen who entered the U.S. before January 1, 1972, or such later date as enacted by law, and has continuously maintained residence in the U.S. since then, and who is not ineligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of an exercise of discretion by the Attorney General under ¶249 of the INA (8 U.S.C. 1259) [amnesty granted under INA 249].
5. Refugee, asylum, or conditional entry status under ¶207, 208 or 203 of INA. A noncitizen who is lawfully present in the U.S. pursuant to an admission under ¶207 of the INA (8 U.S.C. 1157) [refugee status]; pursuant to the granting of asylum (which has not been terminated” under ¶208 of the INA (8 U.S.C. 1158) [asylum status]; or as a result of being granted conditional entry under ¶203(a)(7) of the INA (U.S.C. 1153(a)(7)) before April 1, 1980, because of persecution or fear of persecution on account of race, religion, or political opinion or because of being uprooted by catastrophic national calamity [conditional entry status].
6. Parole status under ¶212(d)(5) of INA. A noncitizen who is lawfully present in the U.S. as a result of an exercise of
discretion by the Attorney General for emergent reasons or reasons deemed strictly in the public interest under 212(d)(5) of the OMA (8 U.S.C. 1182(d)(5)) [parole status].
7. Threat to life or freedom under ¶243(h) of INA. A noncitizen who is lawfully present in the U.S. as a result of the
Attorney General’s withholding deportation under ¶243(h) of the INA (8 U.S.C. 1253 (h)) [threat of life or freedom].
8. Amnesty under ¶245A of INA. A noncitizen lawfully admitted for temporary or permanent residence under ¶245 A of
the INA (8 U.S.C. 1255a) [amnesty granted under INA 245A].
Instructions to Housing Authority: Following verification of status claimed by persons declaring eligible immigration status (other than for noncitizens age 62 or older and receiving assistance on June 19, 1995), the HA must enter INS/SAVE Verification Number and date that it was obtained. A HA signature is not required.
Instructions to Family Member for Completing Form: On opposite page, print or type first name, middle initial(s) and last name. Place and “X” or “√” in the appropriate boxes. Sign and date at bottom of page. Place an “X” or “√” in the box below the signature if the signature is by the adult residing in the unit who is responsible for child.
Notice to applicants and tenants: In order to be eligible to receive the housing assistance sought, each applicant for or recipient of housing assistance must be lawfully within the U.S. Please read the Declaration statement carefully and sign and return to the Housing Authority’s Admissions Office. Please feel free to consult with an immigration lawyer or other immigration expert of your choosing.
I am a citizen, naturalized citizen or national of the United States; or
I have eligible immigration status and I am 62 years of age or older. Attach evidence of proof of age; or
I have eligible immigration status as checked below. Attach INS document(s) evidencing eligible immigration status and signed verification consent form.
Immigrant status under ¶1001(a)(15) or 101(a)(20) of the INA; or
Permanent residence under ¶249 of INA; or
Refugee, asylum, or conditional entry status under ¶207, 208 or 203 of the INA; or
Parole status under ¶212(d)(f) of the INA; or
Threat to life or freedom under ¶243(h) of the INA; or
Amnesty under ¶245 of the INA
Check box if signature of adult residing in the unit who is responsible for child name on statement above.