"Affidavit of Lawful Presence" - Colorado

Affidavit of Lawful Presence is a legal document that was released by the Colorado Department of Health Care Policy and Financing - a government authority operating within Colorado.

Form Details:

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

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Download "Affidavit of Lawful Presence" - Colorado

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AFFIDAVIT
for the Colorado Department of Health Care Policy and Financing as Proof of Lawful Presence in the
United States.
I, ________________________________________________, swear or affirm under penalty of perjury
under the laws of the State of Colorado that (check one):
I am a United States citizen.
I am not a United States citizen but I am a Permanent Resident of the United States.
I am not a United States citizen but I am lawfully present in the United States pursuant to Federal
law.
I am a foreign national not physically present in the United States.
I understand that this sworn statement is required by law because I have applied for a public benefit. I
understand that state law requires me to provide proof that I am lawfully present in the United States
prior to receipt of this public benefit. 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 18-8-503 and it shall constitute a separate
criminal offense each time a public benefit is fraudulently received.
___________________________________________________
_________________________
Signature
Date
___________________________________________________
_________________________
Name (please print)
Social Security Number
Please attach this form to your Electronic Provider Enrollment Application (if applicable).
For questions regarding Health First Colorado enrollment, please call Provider Services at 1-844-235-2387 .
AFFIDAVIT
for the Colorado Department of Health Care Policy and Financing as Proof of Lawful Presence in the
United States.
I, ________________________________________________, swear or affirm under penalty of perjury
under the laws of the State of Colorado that (check one):
I am a United States citizen.
I am not a United States citizen but I am a Permanent Resident of the United States.
I am not a United States citizen but I am lawfully present in the United States pursuant to Federal
law.
I am a foreign national not physically present in the United States.
I understand that this sworn statement is required by law because I have applied for a public benefit. I
understand that state law requires me to provide proof that I am lawfully present in the United States
prior to receipt of this public benefit. 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 18-8-503 and it shall constitute a separate
criminal offense each time a public benefit is fraudulently received.
___________________________________________________
_________________________
Signature
Date
___________________________________________________
_________________________
Name (please print)
Social Security Number
Please attach this form to your Electronic Provider Enrollment Application (if applicable).
For questions regarding Health First Colorado enrollment, please call Provider Services at 1-844-235-2387 .