APPENDIX C. 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

..TX:

\[ \] Permanent residence under 249 of INA 4/; or

..TX:

\[ \]Refugee, asylum, or conditional entry status under

207, 208 or 203 of the INA 5/; or

..TX:

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

..TX:

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

..TX:

\[ \]Amnesty under 245A of the INA 8/.

..TX:

(Signature of Family Member)

(Date)

..TX:

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

is responsible for child named on statement above.

..TX:

HA:Enter INS/SAVE Primary Verification #: Date:

..TX:

\[See reverse side for footnotes and instructions\]

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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 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 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)(20) and 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.

..TX:

4/Permanent residence under 249 of INA. A noncitizen who

e

ntered 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 IHA 249\].

..TX:

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

1253(h))

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\].

..TX:

Instructions to Housing Authority: Following verification of

status

claimed

obtained. A HA signature is not required.

Instructions To Family Member For Complete 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 bottom of page.
Place

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

the adult residing in the unit who is responsible for Child.

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