Form DBO-250.61 "Statement of Citizenship, Alienage, and Immigration Status" - California

What Is Form DBO-250.61?

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.

Form Details:

  • Released on May 1, 2017;
  • The latest edition provided by the California Department of Financial Protection and Innovation;
  • 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 DBO-250.61 by clicking the link below or browse more documents and templates provided by the California Department of Financial Protection and Innovation.

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Download Form DBO-250.61 "Statement of Citizenship, Alienage, and Immigration Status" - California

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STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS
DBO-250.61 (Rev. 5-17)
Print Name of Applicant (the applicant is the individual who wants
Date
the 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
DBO-250.61 (Rev. 5-17)
Print Name of Applicant (the applicant is the individual who wants
Date
the 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
DBO-250.61 (Rev. 5-17) Page 2 of 11
An alien who is granted asylum under Section 208 of the INA.
2.
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 I
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;
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS
DBO-250.61 (Rev. 5-17) Page 3 of 11
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.
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
Date:
Acting For Applicant:
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS
DBO-250.61 (Rev. 5-17) Page 4 of 11
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 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
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS
DBO-250.61 (Rev. 5-17) Page 5 of 11
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:
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).
Page of 11