"Citizenship/Immigration Status Verification Form - '"affidavit'" - Farm Products Program" - Colorado

Citizenship/Immigration Status Verification Form - '"affidavit'" - Farm Products Program is a legal document that was released by the Colorado Department of Agriculture - a government authority operating within Colorado.

Form Details:

  • Released on December 1, 2009;
  • The latest edition currently provided by the Colorado Department of Agriculture;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Colorado Department of Agriculture.

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Download "Citizenship/Immigration Status Verification Form - '"affidavit'" - Farm Products Program" - Colorado

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COLORADO DEPARTMENT OF AGRICULTURE
FARM PRODUCTS PROGRAM
Citizenship/Immigration Status Verification Form- “Affidavit”
Colorado Revised Statutes section 24-76.5-103 requires all state agencies to verify the lawful presence in the United States of
all natural persons (individuals and individuals doing business as sole proprietors) who apply for certain public benefits,
including the license, permit or registration for which you are applying. This requirement applies only to natural persons. It
does not apply to partnerships, corporations or other business entities that apply for state benefits.
If you are applying for a license, permit or registration for yourself, or for a business for which you are the sole proprietor,
you must provide the information requested in numbered paragraphs 1 through 4 on this form, sign and date it, and submit it
along with your application form. If, however, you are applying for a license, permit or registration that will be issued to a
partnership, corporation or other type of business entity, you do not need to fill out this form or submit it.
Alternative Identification Documents: A Colorado ID card; a U.S. Military ID card; a Military Dependent's Card;
a U.S. Coast Guard Merchant Mariner Card; a Native American tribal identification document; a U.S. naturalization
certificate with photograph; a U.S. Passport or other citizenship document with photograph; or valid immigration
documents demonstrating lawful presence (foreign passport with I-551 stamp or attached Temporary I-551 visa,
foreign passport accompanied by an I-94 indicating expiration date, I-94 with refugee or asylum status, Resident
Alien card, Permanent Resident card, Temporary Resident card, Employment Authorization card.) or a driver's
license or identification card issued by a lawful presence state. A list of lawful presence states can be found at this
under Driver’s License, then click on the link for Identification
website :
http://www.colorado.gov/revenue
Requirements (list of lawful presence states is on page 2) or call or email this office.
1.
Print name of individual/sole proprietor:__________________________________________________________
2.
Farm Program registrant business name, if
different:_______________________________________________________
3.
a) Colorado driver's license number:_____________________________ or
b) Alternative identification document as described in paragraph above
(Alternative identification must be a NOTARIZED COPY if not applying in person)
4.
I swear and affirm under penalty of perjury under the laws of the State of Colorado that the information I have
provided on this form is complete and accurate and (check one):
a)____ I am a United States citizen, or
b)____ I am a permanent resident of the United States . PLEASE PROVIDE A COPY OF DOCUMENT
(Provide alien number ______________________ or I-94 number__________________) Date of Birth________
c)____ I am lawfully present in the United States pursuant to Federal law. PLEASE PROVIDE A COPY OF
DOCUMENT
(Provide alien number ______________________ or I-94 number__________________) Date of Birth________
I understand that this sworn statement is required by law because I have applied for a public benefit that is subject to
Colorado Revised Statutes section 24-76.5-103. I understand that this state law requires me to provide proof that I am
lawfully present in the United States prior to receipt of this public benefit. I understand that if I am not a United States
citizen this law requires the Colorado Department of Agriculture ("CDA") to verify my lawful presence in the United States
through the federal Department of Homeland Security ("DHS") Citizenship and Immigration Services ("CIS") Systematic
Alien Verification of Entitlement Program. I hereby authorize DHS/CIS to provide CDA with information related to my
immigration status. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this
sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised
Statute section 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.
Applicant Signature: _______________________________________________________ Date: ____________________
Please mail completed form to:
Colorado Department of Agriculture Farm Products Program
st
2331 W. 31
Avenue
Denver, CO 80211
Phone: (303) 867-9200/Fax: (303) 480-9236
COLORADO DEPARTMENT OF AGRICULTURE
FARM PRODUCTS PROGRAM
Citizenship/Immigration Status Verification Form- “Affidavit”
Colorado Revised Statutes section 24-76.5-103 requires all state agencies to verify the lawful presence in the United States of
all natural persons (individuals and individuals doing business as sole proprietors) who apply for certain public benefits,
including the license, permit or registration for which you are applying. This requirement applies only to natural persons. It
does not apply to partnerships, corporations or other business entities that apply for state benefits.
If you are applying for a license, permit or registration for yourself, or for a business for which you are the sole proprietor,
you must provide the information requested in numbered paragraphs 1 through 4 on this form, sign and date it, and submit it
along with your application form. If, however, you are applying for a license, permit or registration that will be issued to a
partnership, corporation or other type of business entity, you do not need to fill out this form or submit it.
Alternative Identification Documents: A Colorado ID card; a U.S. Military ID card; a Military Dependent's Card;
a U.S. Coast Guard Merchant Mariner Card; a Native American tribal identification document; a U.S. naturalization
certificate with photograph; a U.S. Passport or other citizenship document with photograph; or valid immigration
documents demonstrating lawful presence (foreign passport with I-551 stamp or attached Temporary I-551 visa,
foreign passport accompanied by an I-94 indicating expiration date, I-94 with refugee or asylum status, Resident
Alien card, Permanent Resident card, Temporary Resident card, Employment Authorization card.) or a driver's
license or identification card issued by a lawful presence state. A list of lawful presence states can be found at this
under Driver’s License, then click on the link for Identification
website :
http://www.colorado.gov/revenue
Requirements (list of lawful presence states is on page 2) or call or email this office.
1.
Print name of individual/sole proprietor:__________________________________________________________
2.
Farm Program registrant business name, if
different:_______________________________________________________
3.
a) Colorado driver's license number:_____________________________ or
b) Alternative identification document as described in paragraph above
(Alternative identification must be a NOTARIZED COPY if not applying in person)
4.
I swear and affirm under penalty of perjury under the laws of the State of Colorado that the information I have
provided on this form is complete and accurate and (check one):
a)____ I am a United States citizen, or
b)____ I am a permanent resident of the United States . PLEASE PROVIDE A COPY OF DOCUMENT
(Provide alien number ______________________ or I-94 number__________________) Date of Birth________
c)____ I am lawfully present in the United States pursuant to Federal law. PLEASE PROVIDE A COPY OF
DOCUMENT
(Provide alien number ______________________ or I-94 number__________________) Date of Birth________
I understand that this sworn statement is required by law because I have applied for a public benefit that is subject to
Colorado Revised Statutes section 24-76.5-103. I understand that this state law requires me to provide proof that I am
lawfully present in the United States prior to receipt of this public benefit. I understand that if I am not a United States
citizen this law requires the Colorado Department of Agriculture ("CDA") to verify my lawful presence in the United States
through the federal Department of Homeland Security ("DHS") Citizenship and Immigration Services ("CIS") Systematic
Alien Verification of Entitlement Program. I hereby authorize DHS/CIS to provide CDA with information related to my
immigration status. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this
sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised
Statute section 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.
Applicant Signature: _______________________________________________________ Date: ____________________
Please mail completed form to:
Colorado Department of Agriculture Farm Products Program
st
2331 W. 31
Avenue
Denver, CO 80211
Phone: (303) 867-9200/Fax: (303) 480-9236
FOR CDA OFFICE USE ONLY
If registration issued:
I, ________________________________________, hereby state that I have personally verified the above information by the
following method:
___ Visually inspecting the following document (or notarized copy) produced by the applicant:
__ Colorado driver's license
__ Driver's license from an approved state (specify): ___________________________________________
__ Colorado identification card
__ U.S. military card
__ Military dependent's card
__ U.S. Coast Guard Merchant Mariner card
__ Native American tribal identification document (specify): _____________________________________
__ U.S. naturalization certificate with photograph
__ U.S. Passport
__ One of the following immigration documents verified through SAVE:
__ Foreign passport with I-551 stamp or attached Temporary I-551 visa
__ Foreign passport accompanied by an I-94 indicating expiration date
__ I-94 with refugee or asylum status
__ Resident Alien card
__ Permanent Resident card
__ Temporary Resident card
__ Employment Authorization card
___ Verifying the Colorado driver's license number with the DMV
CDA Employee Signature: _____________________________________________Date:_________________
If registration application not accepted:
I, _________________________________________, hereby state that I was not able to verify the applicant's lawful presence
in the United States for the following reason:
___ The applicant did not provide the required documentation.
___ The information on the documentation provided was not complete or accurate (explain).
________________________________________________________________________________________
___ Other reason: __________________________________________________________________________
CDA Employee Signature: _____________________________________________Date:_________________
************************************************************************************************
I, ___________________________________________, hereby state that I have:
___a) CONFIRMED the applicant's lawful presence in the United States through the SAVE Program;
___b) NOT CONFIRMED the applicant's lawful presence in the United States through the SAVE Program.
CDA Employee Signature: _____________________________________________Date:__________________
Rev. 12-1-09
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