California Code of Regulations › Title 4 - Business Regulations › Division 9 - Division of Measurement Standards, Department of Food and Agriculture › Chapter 12 - Administration › Article 3 - Applicant Verification Regulations › Appendix A

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION
					 STATUS FOR STATE PUBLIC BENEFITS - LICENSURE
Print Name of Applicant
Date
Print Name of Person Acting for Applicant, if any
Relationship to Applicant
STATE PUBLIC BENEFITS TO CITIZENS AND
					 ALIENS
Citizens and nationals of the United States who meet all
					 eligibility requirements may be issued a license, registration or certification
					 by the California Department of Food and Agriculture for employment or to
					 conduct a commercial enterprise and must fill out Sections A and D.
Aliens who meet all eligibility requirements may also be
					 issued a license, registration or certification by the California Department of
					 Food and Agriculture for employment or to conduct a commercial enterprise and
					 must complete Sections A, B, C or D of this form.
SECTION A: CITIZENSHIP/IMMIGRATION STATUS
					 DECLARATION
1. Is the applicant a citizen or national of the United
							 States?
Yes []
No []
If the answer to the above question is yes, where was
					 he/she born? __________(City/State)
2. To establish citizenship or nationality, please submit
					 one of the documents on List A (attached hereto) which is legible and unaltered
					 to establish proof.
IF YOU ARE A CITIZEN OR NATIONAL OF THE UNITED STATES, GO
					 DIRECTLY TO SECTION D. IF YOU ARE AN ALIEN, PLEASE COMPLETE SECTION B, OR, IF
					 APPLICABLE, SECTION C.
SECTION B: ALIEN STATUS DECLARATION
IMPORTANT
: Please indicate the applicant's
					 alien status below, and submit documents evidencing such status. The alien
					 status documents listed for each category are the most commonly used documents
					 that the United States Immigration and Naturalization Service (INS) provides to
					 aliens in those categories. You can provide other acceptable evidence of your
					 alien status even if not listed below.
1.
An alien lawfully admitted for permanent
							 residence under the Immigration and Naturalization Act (INA). (Evidence
							 includes:
[]
*
INS Form I-1551 (Alien Registration Receipt
							 Card, commonly known as a "green card"); or
*
Unexpired Temporary I-561 stamp in foreign
							 passport or on INS Form I-94).
2.
An alien who is granted asylum under
							 section 208 of the INA. (Evidence
							 includes:
[]
*
INS Form I-94 annotated with stamp showing
							 grant of asylum under section
							 208 of the INA;
*
INS form I-688B (Employment Authorization
							 Card) annotated "274a.12(a)(5)";
*
INS Form I-766 (Employment Authorization
							 Document) annotated "A5";
*
Grant letter from the Asylum Office of INS;
							 or
*
Order of an immigration judge granting
							 asylum.)
3.
A refugee admitted to the United States
							 under section
							 207 of the INA. (Evidence
							 includes:
[]
*
INS Form I-94 annotated with stamp showing
							 admission under section
							 207 of the INA;
*
INS Form I-688B (Employment Authorization
							 Card) annotated "274a.12(a)(3)";
*
INS Form I-766 (Employment Authorization
							 Document) annotated "A3"; or
*
INS Form I-571 (Refugee Travel
							 Document).
4.
An alien paroled into the United States for
							 at least one year under section
							 212(d)(5) of the
							 INA. (Evidence includes:
[]
*
INS Form I-94 with stamp showing admission
							 for at least one year under section
							 212(d)(5) of the
							 INA. (Applicant cannot aggregate periods of admission for less than one year to
							 meet the one-year requirement.)).
5.
An alien whose deportation is being
							 withheld under section
							 243(h) of the INA
							 (as in effect immediately prior to September 30, 1996) or Section
							 241(b)(3) of such
							 Act (as amended by section 305(a) of division
							 C of Public Law 104-208. (Evidence
							 includes:
[]
*
INS Form I-688B (Employment Authorization
							 Card) annotated "274a.12(a)(10)";
*
INS Form I-766 (Employment Authorization
							 Document) annotated "A10"; or
*
Order from an immigration judge showing
							 deportation withheld under section
							 243(h) of the INA
							 as in effect prior to April 1, 1997, or removal withheld under section
							 241(b)(3) of the
							 INA).
6.
An alien who is granted conditional entry
							 under section
							 203(a)(7) of the
							 INA as in effect prior to April 1, 1980. (Evidence includes:
[]
*
INS Form I-94 with stamp showing admission
							 under section
							 203(a)(7) of the
							 INA;
*
INS Form I-688B (Employment Authorization
							 Card) annotated "274a.12(a)(3)"; or
*
INS Form I-766 (Employment Authorization
							 Document) annotated "A3").
7.
An alien who is a Cuban or Haitian entrant
							 (as defined in section
							 501(e) of the
							 Refugee Education Assistance Act of 1980). (Evidence includes:
[]
*
INS Form I-551 (Alien Registration Receipt
							 Card, commonly known as a "green card") with the code CU6, CU7, or CH6;
*
Unexpired temporary I-551 stamp in foreign
							 passport or on INS Form I-94 with the code CU6 or CU7; or
*
INS Form I-94 with stamp showing parole as
							 "Cuba/Haitian Entrant" under Section
							 212(d)(5) of the
							 INA).
8.
An alien paroled into the United States for
							 less than one year under section
							 212(d)(5) of the
							 INA. (Evidence includes INS Form I-94 showing this status).
[]
9.
An alien not in categories 1 through 8 who
							 has been admitted to the United States for a limited period of time (a
							 non-immigrant). Non-immigrants are persons who have temporary status for a
							 specific purpose. (Evidence includes INA Form I-94 showing this status).
[]
SECTION C: DECLARATION FOR BATTERED
					 ALIENS
IMPORTANT
: Complete this section if the
					 applicant, the applicant's child or the applicant child's parent has been
					 battered or subjected to extreme cruelty in the United States.
1.
Has the INS or the EOIR granted a petition or
							 application filed by or on behalf of the applicant, the applicant's child, or
							 the applicant's child's parent under the INA or found that a pending petition
							 sets forth a prima facie case? Evidence includes one of the documents on List B
							 (attached hereto).
[]
2.
Has the applicant, the applicant's child, or the
							 applicant child's parent been battered or subjected to extreme cruelty in the
							 United States by a spouse or parent, or by a spouse's or parent's family member
							 living in the same house (where the spouse or parent consented to, or
							 acquiesced in the battery or cruelty)?
[]
SECTION D:
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF
					 THE STATE OF CALIFORNIA THAT THE ANSWERS I HAVE GIVEN ARE TRUE AND CORRECT TO
					 THE BEST OF MY KNOWLEDGE.
___________________________Applicant's Signature:
___________________________Date:
Signature of Person
___________________________Acting for Applicant:
___________________________Date:
LIST A
A person who is a citizen or national of the United
					 States.
A. Primary Evidence
. A birth certificate showing birth in one of the 50
					 States, the District of Columbia, Puerto Rico (on or after January 13, 1941),
					 Guam, the U.S. Virgin Islands (on or after January 17, 1917), American Samoa,
					 Swain's Island or the Northern Mariana Islands, unless the person was born to
					 foreign diplomats residing in the U.S.
Note: If the document shows that the individual was born in
					 Puerto Rico, the U.S. Virgin Islands or the Northern Mariana Islands before
					 these areas became part of the U.S., the individual may be a collectively
					 naturalized citizen--see Paragraph C below.
* United States passport (except limited passports, which
					 are issued for periods of less than five years);
* Report of birth abroad of a U.S. citizen (FS-240)(issued
					 by the Department of State to U.S. citizens);
* Certificate of birth (FS-545) (issued by a foreign
					 service post) or Certification of Report of Birth (DS-1350) (issued by the
					 Department of State), copies of which are available from the Department of
					 State;
* Certificate of Naturalization (N-550 or N-570) (issued by
					 the INS through a Federal or State court, or through administrative
					 naturalization after December 1990 to individuals who are individually
					 naturalized; the N-570 is a replacement certificate issued when the N-550 has
					 been lost or mutilated or the individual's name has been changed);
* Certificate of Citizenship (N-560 or N-561) (issued by
					 the INS to individuals who derive U.S. citizenship through a parent; the N-561
					 is a replacement certificate issued when the N-560 has been lost or mutilated
					 or the individual's name has been changed);
* United States Citizen Identification Card (I-197) (issued
					 by the INS until April 7, 1983 to U.S. citizens living near the Canadian or
					 Mexican border who needed it for frequent border crossings) (formerly Form
					 I-179, last issued in February 1974);
* Northern Mariana Identification Card (issued by the INS
					 to a collectively naturalized citizen of the U.S. who was born in the Northern
					 Mariana Islands before November 3, 1986);
* Statement provided by a U.S. consular officer certifying
					 that the individual is a U.S. citizen (this is given to an individual born
					 outside the U.S. who derives citizenship through a parent but does not have an
					 FS-240, FS-545 or DS-1350); or
* American Indian Card with a classification code "KIC" and
					 a statement on the back (identifying U.S. citizen members of the Texas Band of
					 Kickapoos living near the U.S./Mexican border).
B. Secondary Evidence
If the applicant cannot present one of the documents listed
					 in A above, the following may be relied upon to establish U.S. citizenship or
					 nationality:
* Religious record recorded in one of the 50 States, the
					 District of Columbia, Puerto Rico (on or after January 13, 1941), Guam, the
					 U.S. Virgin Islands (on or after January 17, 1917)), American Samoa, Swain's
					 Island or the Northern Mariana Islands (unless the person was born to foreign
					 diplomats residing in such a jurisdiction) within three months after birth
					 showing that the birth occurred in such jurisdiction and the date of birth or
					 the individual's age at the time the record was made;
* Evidence of civil service employment by the U.S.
					 government before June 1, 1976;
* Early school records (preferably from the first school)
					 showing the date of admission to the school, the child's date and place of
					 birth, and the name(s) and place(s) of birth of the parent(s);
* Census record showing name, U.S. citizenship or a U.S.
					 place of birth, and date of birth or age of applicant;
* Adoption Finalization Papers showing the child's name and
					 place of birth in one of the 50 States, the District of Columbia, Puerto Rico
					 (on or after January 13, 1941), Guam, the U.S. Virgin Islands (on or after
					 January 17, 1917), American Samoa, Swain's Island or the Northern Mariana
					 Islands (unless the person was born to foreign diplomats residing in such a
					 jurisdiction) or, where or adoption is not finalized and the State or other
					 jurisdiction listed above in which the child was born will not release a birth
					 certificate prior to final adoption, a statement from a state-approved adoption
					 agency showing the child's name and place of birth in one of such jurisdictions
					 (NOTE: the source of the information must be an original birth certificate and
					 must be indicated in the statement); or
* Any other document that establishes a U.S. place of birth
					 or in some way indicates U.S. citizenship (e.g., a contemporaneous hospital
					 record of birth in that hospital in one of the 50 States, the District of
					 Columbia, Puerto Rico (on or after January 13, 1941), Guam, the U.S. Virgin
					 Islands (on or after January 17, 1917), American Samoa, Swain's Island or the
					 Northern Mariana Islands (unless the person was born to foreign diplomats
					 residing in such a jurisdiction).
C. Collective Naturalization
If the applicant cannot present one of the documents listed
					 in A or B above, the following will establish U.S. citizenship for collectively
					 naturalized individuals:
Puerto Rico:
* Evidence of birth in Puerto Rico on or after April 11,
					 1899 and the applicant's statement that he or she was residing in the U.S., a
					 U.S. possession or Puerto Rico on January 13, 1941; or
* Evidence that the applicant was a Puerto Rican citizen
					 and the applicant's statement that he or she was residing in Puerto Rico on
					 March 1, 1917 and that he or she did not take an oath of allegiance to
					 Spain.
U.S. Virgin Islands:
* Evidence of birth in the Virgin Islands, and the
					 applicant's statement of residence in the U.S., a U.S. possession or the U.S.
					 Virgin Islands on February 25, 1927;
* The applicant's statement indicating resident in the U.S.
					 Virgin Islands as a Danish citizen on January 17, 1917 and residence in the
					 U.S., a U.S. possession or the U.S. Virgin Islands on February 25, 1927, and
					 that he or she did not make a declaration to maintain Danish citizenship;
					 or
* Evidence of birth in the U.S. Virgin Islands and the
					 applicant's statement indicating residence in the U.S., a U.S. possession or
					 territory or the Canal Zone on June 28, 1932.
Northern Mariana Islands (NMI) (formerly part of the Trust
					 Territory of the Pacific Islands (TTPI)):
* Evidence of birth in the NMI, TTPI citizenship and
					 residence in the NMI, the U.S., or a U.S. territory or possession on November
					 3, 1986 (NMI local time) and the applicant's statement that he or she did not
					 owe allegiance to a foreign state on November 4, 1986 (NMI local time);
* Evidence of TTPI citizenship, continuous residence in the
					 NMI since before November 3, 1981 (NMI local time), voter registration prior to
					 January 1, 1975 and the applicant's statement that he or she did not owe
					 allegiance to a foreign state on November 4, 1986 (NMI local time); or
* Evidence of continuous domicile in the NMI since before
					 January 1, 1974 and the applicant's statement that he or she did not owe
					 allegiance to a foreign state on November 4, 1986 (NMI local time).
Note: If a person entered the NMI as a nonimmigrant and
					 lived in the NMI since January 1, 1974, this does not constitute continuous
					 domicile and the individual is not a U.S. citizen.
D. Derivative Citizenship
If the applicant cannot present one of the documents listed
					 in A or B above, you should make a determination of derivative U.S. citizenship
					 in the following situations:
Applicant born abroad to two U.S. citizen parents:
* Evidence of the U.S. citizenship of the parents and the
					 relationship of the applicant to the parents, and evidence that at least one
					 parent resided in the U.S. or an outlying possession prior to the applicant's
					 birth.
Applicant born abroad to a U.S. citizen parent and a U.S.
					 non-citizen national parent:
* Evidence that one parent is a U.S. citizen and that the
					 other is a U.S. non-citizen national, evidence of the relationship of the
					 applicant to the U.S. citizen parent, and evidence that the U.S. citizen parent
					 resided in the U.S., a U.S. possession, American Samoa or Swain's Island for a
					 period of at least one year prior to the applicant's birth.
Applicant born out of wedlock abroad to a U.S. citizen
					 mother:
* Evidence of the U.S. citizenship of the mother, evidence
					 of the relationship to the applicant and, for births on or before December 24,
					 1952, evidence that the mother resided in the U.S. prior to the applicant's
					 birth or, for births after December 24, 1952, evidence that the mother had
					 resided, prior to the child's birth, in the U.S. or a U.S. possession for a
					 period of one year.
Applicant born in the Canal Zone or the Republic of
					 Panama:
* A birth certificate showing birth in the Canal Zone on or
					 after February 26, 1904 and before October 1, 1979 and evidence that one parent
					 was a U.S. citizen at the time of the applicant's birth; or
* A birth certificate showing birth in the Republic of
					 Panama on or after February 26, 1904 and before October 1, 1979 and evidence
					 that at least one parent was a U.S. citizen and employed by the U.S. government
					 or the Panama Railroad Company or its successor in title.
All other situations where an applicant claims to have a
					 U.S. citizen parent and an alien parent, or claims to fall within one of the
					 above categories but is unable to present the listed documentation:
* If the applicant is in the U.S., refer him or her to the
					 local INS office for determination of U.S. citizenship;
* If the applicant is outside the U.S., refer him or her to
					 the State Department for a U.S. citizenship determination.
E. Adoption of Foreign-Born Child by U.S.
					 Citizen
* If the birth certificate shows a foreign place of birth
					 and the applicant cannot be determined to be a naturalized citizen under any of
					 the above criteria, obtain other evidence of U.S. citizenship;
* Since foreign-born adopted children do not automatically
					 acquire U.S. citizenship by virtue of adoption by U.S. citizens, refer the
					 applicant to the local INS district office for a determination of U.S.
					 citizenship if the applicant provides no evidence of U.S. citizenship.
F. U.S. Citizenship By Marriage
A women acquired U.S. citizenship through marriage to a
					 U.S. citizen before September 22, 1922. Ask for: Evidence of U.S. citizenship
					 of the husband, and evidence showing the marriage occurred before September 22,
					 1922.
Note: If the husband was an alien at the time of the
					 marriage, and became naturalized before September 22, 1922, the wife also
					 acquired naturalized citizenship. If the marriage terminated, the wife
					 maintained her U.S. citizenship if she was residing in the U.S. at that time
					 and continued to reside in the U.S.
LIST B
A. Documentation Evidencing an Apzproved Petition or
					 Application
. INS Form I-551 ("Resident Alien Card" or "Alien
					 Registration Receipt Card", commonly known as a "green card") with one of the
					 following INS class of admission ("COA") codes printed on the front of a white
					 card or the back of a pink card: AR1, AR6, C20 through C29, CF1, CF2, CR1, CR2,
					 CR6, CR7, CX1 through CX3, CX6 through CX8, F20 through F29, FX1 through FX3,
					 FX6 through FX8, IF1, IF2, IR1 through IR4, IR6 through IR9, IW1, IW2, IW6,
					 IW7, MR6, MR7, P21 through P23, or P26 through P28.
If an alien claiming approved status presents a code
					 different than those enumerated, or if you cannot determine the class of
					 admission from the I-551 stamp, file INS Form G-845, and the G-845 Supplement
					 (mark item six on the Supplement) (attached hereto) along with a copy of the
					 document(s) presented, with the local INS office in order to determine whether
					 the applicant gained his or her status because he or she was the spouse, widow,
					 or child of a U.S. citizen or the spouse, child, or unmarried son or daughter
					 of an LPR ("lawful permanent resident").
* INS Form I-551 with one of the following COA codes
					 stamped on the lower left side of the back of a pink card: IB1 through IB3, IB6
					 through IB8, B11, B12, B16, B17, B20 through B29, B31 through B33, B36 through
					 B38, BX1 through BX3, or BX6 through BX8.
* INS Form I-551 with COA code Z13.
* Unexpired Temporary I-551 stamp in foreign passport or on
					 INS Form I-94 with one of the COA codes specified in the Subsections (1)-(3),
					 above.
* INS Form I-797 indicating approval of an INS I-130
					 petition (only I-130 petitions describing the following relationships may be
					 accepted: husbands or wives of U.S. citizens or LPRs, unmarried children under
					 21 years old of U.S. citizens or LPRs, or unmarried children 21 or older of
					 LPRs), or approval of an I-360 petition (only I-360 approvals based on status
					 as a widow/widower of a U.S. citizen or as a self-petitioning spouse or child
					 of an abusive U.S. citizen or LPR may be accepted).
* A final order of an Immigration Judge or the Board of
					 Immigration Appeals granting suspension of deportation under section
					 244(a)(3) of the
					 INA as in effect prior to April 1, 1997, or cancellation of removal under
					 section 240 A(b)(2) of the INA.
B. Documentation Demonstrating that the Applicant has
					 Established a Prima Facie Case
* INS Form I-797 indicating that the applicant has
					 established a prima facie case; or
* An immigration court or Board of Immigration Appeals
					 order indicating that the applicant has established a prima facie case for
					 suspension of deportation under INA section
					 244(a)(3) as in
					 effect prior to April 1, 1997, or cancellation of removal under section
					 240 A(b)(2) of the INA.
C. Documentation Indicating that the Applicant has
					 Filed a Petition or that a Petition has been Filed on the Applicant's Behalf,
					 as Applicable, but with no Evidence of Approval of the Petition or
					 Establishment of a Prima Facie Case
The benefit provider shall determine from the documentation
					 when the petition was filed and take the actions set forth below:
* Applicants with petitions filed before June 7, 1997
					 should have an INS Form I-797 indicating filing of the I-360 petition by
					 "self-petitioning spouse [or child] of abusive U.S.C. or LPR," a file-stamped
					 copy of the petition, or another document demonstrating filing (including a
					 cash register or computer-generated receipt indicating filing of Form
					 I-360).
* Applicants with petitions filed after June 7, 1997 should
					 have an INS Form I-797 indicating filing of the I-360 petition.
D. Documentation Indicating that the Applicant has
					 filed a Petition or that a Petition was filed on His or Her Behalf, as
					 Applicable
The following must indicate that the applicant is the
					 widow/widower of a U.S. citizen, the husband or wife of a U.S. Citizen or LPR,
					 the unmarried child under age 21 of a U.S. citizen or LPR, or the unmarried
					 child age 21 or older of an LPR):
* For aliens on whose behalf a petition has been filed: INS
					 Form I-797 indicating filing of an INS I-130 petition, a file-stamped copy of
					 the petition, or another document demonstrating filing (including a cash
					 register or computer-generated receipt indicating filing of Form I-130) (a
					 sample copy of Form I-130 is attached to this Exhibit).
* For self-petitioning widows or widowers: a file-stamped
					 copy of the INS I-360 petition, or another document demonstrating filing
					 (including a cash register or computer-generated receipt indicating filing of
					 Form I-360).
E. Documentation Indicating that the INS has
					 Initiated Deportation or Removal Proceedings in which Relief may be
					 Available
* an "Order to Show Cause";
* a "Notice to Appear"; or
* a "Notice of Hearing in Deportation Proceedings."
F. Minimal or no Documentation Regarding the Claimed
					 Filing
If the applicant has some documentation, but it is
					 insufficient to demonstrate filing, establishment of prima facie case or
					 approval of a petition, fax the INS Request Form on your agency letterhead, as
					 well as a copy of any document(s) provided by the applicant, to the INS Vermont
					 Service Center in order to determine the applicant's status. If the applicant
					 has no documentation, but is certain that a petition has been filed by his or
					 her spouse or parent, fax the INS Request Form to the INS Vermont Service
					 Center.