Form ABC-69 "Statement of Citizenship, Alienage, and Immigration Status for State Public Benefits" - California

What Is Form ABC-69?

This is a legal form that was released by the California Department of Alcoholic Beverage Control - 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 April 1, 2003;
  • The latest edition provided by the California Department of Alcoholic Beverage Control;
  • 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 fillable version of Form ABC-69 by clicking the link below or browse more documents and templates provided by the California Department of Alcoholic Beverage Control.

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Download Form ABC-69 "Statement of Citizenship, Alienage, and Immigration Status for State Public Benefits" - California

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STATE OF CALIFORNIA
DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL
STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS FOR STATE PUBLIC BENEFITS
Name of Applicant/Licensee
Today's Date
(Print Last, First and Middle Names)
ABC License No(s).
(Current licensees only) ( Identify all licenses you possess).
What
to
complete
Citizens and nationals of the United States who meet all eligibility requirements may receive a California
alcoholic beverage license and must complete Sections A and D.
Aliens who meet all eligibility requirements may also receive a California alcoholic beverage license and must
complete Sections A, B, C (if applicable), and D of this form.
What
to
submit
Completed ABC-69 with original signature(s). Photocopies and fax copies are not acceptable.
Supporting document(s). See List A and B.
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 were you born?
(City and State)
2.
To establish citizenship or nationality, please submit a copy of one of the documents on List A (attached hereto)
or a certified copy of your birth certificate 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 AND D, AND, IF NECESSARY, SECTION C.
SECTION B:
ALIEN STATUS DECLARATION
Please indicate your alien status below, and submit copies of both sides (front and back) of the
IMPORTANT:
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 the category.
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
❒ 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.)
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STATE OF CALIFORNIA
DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL
STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS FOR STATE PUBLIC BENEFITS
Name of Applicant/Licensee
Today's Date
(Print Last, First and Middle Names)
ABC License No(s).
(Current licensees only) ( Identify all licenses you possess).
What
to
complete
Citizens and nationals of the United States who meet all eligibility requirements may receive a California
alcoholic beverage license and must complete Sections A and D.
Aliens who meet all eligibility requirements may also receive a California alcoholic beverage license and must
complete Sections A, B, C (if applicable), and D of this form.
What
to
submit
Completed ABC-69 with original signature(s). Photocopies and fax copies are not acceptable.
Supporting document(s). See List A and B.
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 were you born?
(City and State)
2.
To establish citizenship or nationality, please submit a copy of one of the documents on List A (attached hereto)
or a certified copy of your birth certificate 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 AND D, AND, IF NECESSARY, SECTION C.
SECTION B:
ALIEN STATUS DECLARATION
Please indicate your alien status below, and submit copies of both sides (front and back) of the
IMPORTANT:
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 the category.
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
❒ 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.)
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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 s243(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) or 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
Complete this section if you or your child, or your child's parent has been battered or subjected to
IMPORTANT:
extreme cruelty in the United States.
1.
Has the INS or the Executive Office of Immigration Review (EOIR) granted a petition or application filed by or
on behalf of the application, 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).
Yes
No
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 to the battery or cruelty)? Yes
No
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:
Applicant's Printed Name:
(
)
Applicant's Home Address:
Address
Street
Daytime Telephone Number
City
State
Country
Signature of Person
Acting For Applicant:
Date:
(
)
Printed Name of Person Acting for Applicant
Daytime Telephone Number
RETURN WITH APPLICATION OR LICENSE RENEWAL NOTICE and FEES
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Do Not Return Lists A and B To ABC
LIST A
A person who is a citizen or national of the United States.
A. Primary Evidence
• A birth certificate showing a 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 N570 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:
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• 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
the
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 U.S. 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 residence 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
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• 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.
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