Fill and Sign the Residency Lawful 497331119 Form

Certification of Citizenship, Residency, or Lawful Immigration Status I am (check, if applicable, one of the following): [ ] A citizen of the United States. I currently reside at ________________________ _____________________________________ (street address, city, state, zip code) , and have resided at that address since ___________________ (date) . Prior to said date, I resided at ________________________________________________________ _____________ (street address, city, state, zip code) , from ___________________ (date) to ___________________ (date) . [ ] An alien with lawful permanent, conditional, or temporary resident status. [ ] An alien in a nonimmigrant visa status, and the initial period of admission either has not expired or has been extended. Visa Type: ___________________ [ ] An alien in a refugee or asylee status, and such status has not expired or been revoked. [ ] An alien in a parole status, and such status has not expired, been revoked, or been terminated. I understand that I am required to present to _______________________ (Name of Position) , or other person designated by the _______________________________________ (Organization requiring certification) , document(s) as specified below in order to verify that the information set out above is true and correct. By signing below, I represent that the information I have provided in this certification is true and correct, and that any document(s) I present is/are genuine. I understand that false or misleading information or documents related to this certification may subject me to __________ ____________________________________________ (type of penalty) , as well as other legal sanctions. I understand that acceptable documents to present are described in Exhibit A attached hereto. Name of Document ___________________________________________________ Issuing Authority ______________________________________________________ Document Number, if any ________________________________________________ Expiration Date, if any ____________________________________________________ Name of Document ___________________________________________________ Issuing Authority ______________________________________________________ Document Number, if any ________________________________________________ Expiration Date, if any ____________________________________________________ Name of Document ___________________________________________________ Issuing Authority ______________________________________________________ Document Number, if any ________________________________________________ Expiration Date, if any ____________________________________________________ Name of Document ___________________________________________________ Issuing Authority ______________________________________________________ Document Number, if any ________________________________________________ Expiration Date, if any ____________________________________________________ Witness my signature this ___________________ (date) . Printed Name _______________________________________________ Signature ___________________________________________________