APPENDIX 6

MODEL DECLARATION OF SECTION 214 STATUS

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, \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
certify, under penalty of perjury

1/, that, to the best of my knowledge, I am lawfully within the United

States because (please check the appropriate box):

\_\_\_ I am a citizen by birth, a naturalized citizen or a 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; 2/ or

\_\_\_ I have eligible immigration status as checked below (see reverse

side of this form for explanations). Attach INS document(s)

evidencing eligible immigration status and signed verification

consent form.

\_\_\_ Immigrant status under §§101(a)(15) or 101(a)(20) of the

Immigration and Nationality Act (INA); 3/ or

\_\_\_ Permanent residence under §249 of INA; 4/ or

\_\_\_ Refugee, asylum, or conditional entry status under §§207, 208

or 203 of the INA; 5/ or

\_\_\_ Parole status under §§212(d)(5) of the INA; 6/ or

\_\_\_ Threat to life or freedom under §243(h) of the INA; 7/ or

\_\_\_ Amnesty under §245A,of the INA. 8/

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Signature of Family Member) (Date)

\_\_\_ Check box on left if signature is of adult residing in the unit
who

is responsible for child named on statement above.

HA: Enter INS/SAVE Primary Verification #:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date:\_\_\_\_\_\_

\[See next page for footnotes and instructions\]

\-- SAMPLE \-- Appendix 6

A-6.1

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,

or 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 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 Nationally Act (INA), as an immigrant, as defined by

101(a)(15) of the INA (8 U.S.C. 1101(a)(20) and 1101(a)(15),
respectively

\[immigrant status\]. This category includes a noncitizen admitted under
210

or 201A of the INA (8 U.S.C. 1160 and 1161), \[special agricultural
worker

status\], who has been granted lawful temporary residence 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

iineligible 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 INA (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 to life
or

freedom\].

8/ Amnesty under 245A of INA. A noncitizen lawfully admitted for
temporary or

permanent residence under §245A 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), 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 an \"X\" or
\"check\" in

the appropriate boxes. Sign and date at the bottom of the page. Place an
\"X\"

or \"check\" in the box below the signature if the signature is by an
adult

residing in the unit who is responsible for the child in the statement.

\-- SAMPLE \-- Appendix 6

A-6.2