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DECLARATION OF SECTION 214 STATUS <br />Notice to applicants and tenants: In order to be eligible to receive the housing assistance <br />sought, each applicant for or recipient of housing assistance must be lawfully within the <br />United States. Please read the Declaration statement carefully and sign and return to the <br />Housing Authority’s Admissions Office. Please feel free to consult with an immigration <br />lawyer or other immigration expert of your choosing. <br />I, ___________________________________________ certify, under penalty of perjury, that to <br />the best of my knowledge, I am lawfully within the United States because: <br />[ ] I am a citizen by birth, naturalized citizen or national of the United States. <br />OR: <br />[ ] I have eligible immigration status and I am 62 years of age or older (attach proof of age). <br />OR: <br />[ ] I have eligible immigration status as checked below (see reverse side of this form for <br />explanations). Attach INS document(s) evidencing eligible immigration status and <br />signed verification consent form. <br /> [ ] Immigrant status under #1001(a)(15) or 101(a)(20) of the INA <br />OR: <br /> [ ] Permanent residence under #249 of INA <br /> OR: <br /> [ ] Refugee, asylum or conditional entry status under #207, 208 or 203 of the <br /> INA <br /> OR: <br /> [ ] Parole status under #212(d)(f) of the INA <br /> OR: <br /> [ ] Threat to life of freedom under #243(h) of the INA <br /> OR: <br /> [ ] Amnesty under #254 of the INA <br />___________________________________ _____________________________ <br />Signature of Family Member Date <br />[ ] Check box if signature of adult residing in the unit is responsible for a child named on <br />statement above. <br />HA: Enter INS/SAVE Primary Verification # ____________________ Date________ <br />Warning: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and <br />willfully makes or uses a document or writing containing any false, fictitious or fraudulent <br />statement or entry, in any manner within the jurisdiction of any department or agency of <br />the United States, shall be fined not more than $10,000 or imprisoned for not more than five <br />years, or both. <br />[See reverse side for footnotes and instructions] <br />Page 12 of 29 <br />EXHIBIT 2