Form DHCS5111 "Statement of Citizenship, Alienage, and Immigration Status for State Public Benefits" - California

What Is Form DHCS5111?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2013;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHCS5111 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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STATE OF CALIFORNIA--HEALTH AND HUMAN SERVICES AGENCY
Department of Health Care Services
Licensing and Certification Branch, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
Application Supplement
FOR SOLE PROPRIETORS ONLY
This supplement is to be completed by all sole proprietors who are applying for licensure or alcohol and
drug program certification with the Department of Health Care Services (DHCS).
The information requested is necessary to assist the Department in implementing the federal mandate
under Section 411 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA)
of 1996 (Public Law 104-193). Licensing and certification are considered public benefits. Therefore,
under this federal law, persons who are not citizens and are not described in the federal law as qualified
aliens, nonimmigrant aliens under the Immigration and Nationality Act (INA), or aliens paroled into the
United States for less than one year under Section 212(d)(5) of the INA are ineligible to receive state
public benefits.
Sole proprietors are required to complete the attached Statement of Citizenship, Alienage, and
Immigration Status for State Public Benefits [Form DHCS 10045 (6/2013)] and return with your completed
application.
DHCS 5111 (07/13)
Page 1 of 10
STATE OF CALIFORNIA--HEALTH AND HUMAN SERVICES AGENCY
Department of Health Care Services
Licensing and Certification Branch, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
Application Supplement
FOR SOLE PROPRIETORS ONLY
This supplement is to be completed by all sole proprietors who are applying for licensure or alcohol and
drug program certification with the Department of Health Care Services (DHCS).
The information requested is necessary to assist the Department in implementing the federal mandate
under Section 411 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA)
of 1996 (Public Law 104-193). Licensing and certification are considered public benefits. Therefore,
under this federal law, persons who are not citizens and are not described in the federal law as qualified
aliens, nonimmigrant aliens under the Immigration and Nationality Act (INA), or aliens paroled into the
United States for less than one year under Section 212(d)(5) of the INA are ineligible to receive state
public benefits.
Sole proprietors are required to complete the attached Statement of Citizenship, Alienage, and
Immigration Status for State Public Benefits [Form DHCS 10045 (6/2013)] and return with your completed
application.
DHCS 5111 (07/13)
Page 1 of 10
STATE OF CALIFORNIA--HEALTH AND HUMAN SERVICES AGENCY
Department of Health Care Services
Licensing and Certification Branch, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS FOR STATE PUBLIC BENEFITS
Print Name of Applicant (the applicant is the person who wants to be
Date
licensed or certified)
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
receive public benefits, and must fill out Sections A and D.
Aliens, who meet all eligibility requirements, may also receive public benefits and must complete
Sections A, B, C, and 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.
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, AND, IF NECESSARY, 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 is 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-551 (Alien Registration Receipt Card, commonly known as a “green card”); or
DHCS 5111 (07/13)
Page 2 of 10
STATE OF CALIFORNIA--HEALTH AND HUMAN SERVICES AGENCY
Department of Health Care Services
Licensing and Certification Branch, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
Unexpired temporary I-551 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”.
DHCS 5111 (07/13)
Page 3 of 10
STATE OF CALIFORNIA--HEALTH AND HUMAN SERVICES AGENCY
Department of Health Care Services
Licensing and Certification Branch, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
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 (-551 (Alien Registration Receipt Card, commonly known as a "green
card") with the code CU6, CU7, a 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 "Cuban/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 INS 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 applicants child's parent under the INA or found that a
pending petition sets forth a prima facie case? Evidence includes 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:
DHCS 5111 (07/13)
Page 4 of 10
STATE OF CALIFORNIA--HEALTH AND HUMAN SERVICES AGENCY
Department of Health Care Services
Licensing and Certification Branch, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
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:
DHCS 5111 (07/13)
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