Form DBO-CDDTL250.61 "Statement of Citizenship, Alienage and Immigration Status for Application of Department of Business Oversight License or Certificate" - California

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

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  • Released on May 1, 2017;
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Download Form DBO-CDDTL250.61 "Statement of Citizenship, Alienage and Immigration Status for Application of Department of Business Oversight License or Certificate" - California

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STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
STATEMENT OF CITIZENSHIP, ALIENAGE AND IMMIGRATION STATUS
FOR APPLICATION OF DEPARTMENT OF BUSINESS OVERSIGHT LICENSE
OR CERTIFICATE
DBO–CDDTL 250.61 (Rev. 5-17)
Print Name of Applicant (the applicant is the individual who wants the
Date
license or certificate).
Print Name of Person Acting for Applicant, if any.
Relationship to
Applicant
LICENSES AND CERTIFICATES TO CITIZENS AND ALIENS
Citizens and nationals of the United States who meet all eligibility requirements and apply for a
license or certificate must fill out Sections A and D of this form.
Aliens who meet all eligibility requirements and apply for a license or certificate must complete
Sections A, B, C (if applicable), 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 must be legible and unaltered to establish proof.
IF YOU ARE A CITIZEN OR NATIONAL OF THE UNITED STATES, PROCEED DIRECTLY TO
SECTION D. IF YOU ARE AN ALIEN, PLEASE COMPLETE SECTION B, SECTION C (IF
APPLICABLE), AND SECTION D.
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-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.
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
STATEMENT OF CITIZENSHIP, ALIENAGE AND IMMIGRATION STATUS
FOR APPLICATION OF DEPARTMENT OF BUSINESS OVERSIGHT LICENSE
OR CERTIFICATE
DBO–CDDTL 250.61 (Rev. 5-17)
Print Name of Applicant (the applicant is the individual who wants the
Date
license or certificate).
Print Name of Person Acting for Applicant, if any.
Relationship to
Applicant
LICENSES AND CERTIFICATES TO CITIZENS AND ALIENS
Citizens and nationals of the United States who meet all eligibility requirements and apply for a
license or certificate must fill out Sections A and D of this form.
Aliens who meet all eligibility requirements and apply for a license or certificate must complete
Sections A, B, C (if applicable), 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 must be legible and unaltered to establish proof.
IF YOU ARE A CITIZEN OR NATIONAL OF THE UNITED STATES, PROCEED DIRECTLY TO
SECTION D. IF YOU ARE AN ALIEN, PLEASE COMPLETE SECTION B, SECTION C (IF
APPLICABLE), AND SECTION D.
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-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.
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
STATEMENT OF CITIZENSHIP, ALIENAGE AND IMMIGRATION STATUS
FOR APPLICATION OF DEPARTMENT OF BUSINESS OVERSIGHT LICENSE
OR CERTIFICATE
DBO–CDDTL 250.61 (Rev. 5-17) Page 2 of 10
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 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.
5.
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".
6.
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 "Cuban/Haitian
Entrant" under Section 212(d)(5) of the INA.
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
STATEMENT OF CITIZENSHIP, ALIENAGE AND IMMIGRATION STATUS
FOR APPLICATION OF DEPARTMENT OF BUSINESS OVERSIGHT LICENSE
OR CERTIFICATE
DBO–CDDTL 250.61 (Rev. 5-17) Page 3 of 10
7.
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.)
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 status 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 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
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
STATEMENT OF CITIZENSHIP, ALIENAGE AND IMMIGRATION STATUS
FOR APPLICATION OF DEPARTMENT OF BUSINESS OVERSIGHT LICENSE
OR CERTIFICATE
DBO–CDDTL 250.61 (Rev. 5-17) Page 4 of 10
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 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
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
STATEMENT OF CITIZENSHIP, ALIENAGE AND IMMIGRATION STATUS
FOR APPLICATION OF DEPARTMENT OF BUSINESS OVERSIGHT LICENSE
OR CERTIFICATE
DBO–CDDTL 250.61 (Rev. 5-17) Page 5 of 10
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 diplomates 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 may be
relied upon to 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.