Sign and date below and return to the name and address specified in the attached notification letter. If this block is checked on behalf of a child, the adult who will reside in the assisted unit and who is responsible for the child should sign and date below.

NOTE: If you checked this block and you are 62 years of age or older, you need only submit a proof of age document together with this format, and sign below:

If you checked this block and you are less than 62 years of age, you should submit the following documents:

a. Verfication Consent Format (see Sample Verification Consent Form in Exhibit 3-6).

AND

b. One of the following documents:

(1) Form I-551, *Permanent Resident Card*

(2) Form I-94, Arrival-Departure Record, with one of the following annotations: (a) "Admitted as Refugee Pursuant to section 207"; (b) "Section 208" or "Asylum"; (c) "Section 243(h)" or "Deportation stayed by Attorney General"; or (d) "Paroled Pursuant to Sec. 212(d5) of the INA.'

(3) If Form I-94, Arrival-Departure Record, is not annotated, it must be accompanied by one of the following documents: (a) A final court decision granting asylum (but only if no appeal is taken); (b) A letter from an DHS asylum officer granting asylum (if application was filed on or after October 1, 1990) or from an DHS district director granting asylum (if application was filed before October 1, 1990); (c) A court decision granting withholding or deportation; or (d) A letter from an DHS asylum officer granting withholding of deportation (if application was filed on or after October 1, 1990

(6) A receipt issued by the DHS indicating that an application for issuance of a replacement document in one of the above-listed categories has been made and that the applicant's entitlement to the document has been verified.

(7) *Other acceptable evidence. If other documents are determined by the DHS to constitute acceptable evidence of immigration status, they will be announced by notice published in the Federal Register.*

If this block is checked, sign and date below and submit the documentation required above with this declaration and a verification consent format to the name and address specified in the attached notification. If this block is checked on behalf of a child, the adult who will reside in the assisted unit and who is responsible for the child should sign and date below.

If for any reason, the documents shown in subparagraph 2.b. above are not currently available, complete the Request for Extension block below.

 

[] 3. I am not contending eligible immigration status and I understand that I am not eligible for financial assistance.

If you checked this block, no further information is required, and the person named above is not eligible for assistance. Sign and date below and forward this format to the name and address specified in the attached notification. If this block is checked on behalf of a child, the adult who is responsible for the child should sign and date below.

1/ Warning: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and willfully makes or usesaor writing containing any false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000, 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 eligible immigration status is required.

3/Immigrant status under $$101(a15) or 101(a20) of INA. A noncitizen lawfully admitted for permanent residence, as definedby 101(a20) of the Immigration and Nationality Act (INA), as an immigrant, as defined by 101(a15) of the INA (8 U.S.C. 110(a20) and 110(a15), 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

4/Permanent residence under §249 of INA. A noncitizen who entered the U.S. before January1, 1092, 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 $§207c 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 (whichhas 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 (a7) of the INA (U.S.C. 1153(a7 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/status under $212(d5) of INA. A noncitizen who is lawfully present in the U.S. as a result of an exercise of discretion Parole by the Attorney General for emergent reasons or reasons deemed strictly in the public interest under $212(d5) of the INA (8 U.S.C. 1182(d5 [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 to life or freedom]. permanent residence under §245A of 8/ Amnesty under §245A of INA. A noncitizen lawfully admitted for temporary or the INA (8 U.S.C. 1255a) [amnesty granted under INA 245A]