Declaration Of Section 214 Status Page 2
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Warning: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and willfully makes or uses a document or
writing containing any false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any
department or agency of the United States, shall be fined not more than $10,000, imprisioned for not more than five years, or
both.
The following footnotes pertain to noncitizens who declare eligible immigration status in one of the following categories:
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Eligible immigration status and 62 years of age or older. For noncitizens who are 62 years of age or older or who
will be 62 years of age or older and receiving assistance under a Section 214 covered program on June 19, 1995. If
you are eligible and elect to select this category, you must include a document providing evidence of proof of age.
No further documentation of eligible immigration status is required.
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Immigrant status under §§101(a)(15) or 101(a)(20) of INA. A noncitizen lawfully admitted for permanent
residence, as defined by §101(a)(20) of the Immigration and Nationality Act (INA), as an immigrant, as defined by
§101(a)(15) of the INA (8 U.S.C. 1101(a)(20) and 1101(a)(15), respectively [immigrant status]. This category
includes a noncitizen admitted under §§210 or 210A of the INA (8 U.S.C. 1160 or 1161), [special agricultural
worker status], who has been granted lawful temporary resident status.
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Permanent residence under §249 of INA. A noncitizen who entered the U.S. before January 1, 1972, or such later
date as enacted by law, and has continuously maintained residence in the U.S. since then, and who is not ineligible
for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of an exercise of
discretion by the Attorney General under §249 of the INA (8 U.S.C. 1259) [amnesty granted under INA 249].
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Refugee, asylum, or conditional entry status under §§207, 208, or 203 of INA. A noncitizen who is lawfully
present in the U.S. pursuant to an admission under §207 of the INA (8 U.S.C. 1157) [refugee status]; pursuant to the
granting of asylum (which has not been terminated) under §208 of the INA (U.S.C. 1153(a)(7)) before April 1,
1980, because of persecution or fear of persecution on account of race, religion, or political opinion or because of
being uprooted by catastrophic national calamity [conditional entry status].
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Parole status under §212(d)(5) of INA. A noncitizen who is lawfully present in the U.S. as a result of an exercise
of discretion by the Attorney General for emergent reasons or reasons deemed strictly in the public interest under
§212(d)(5) of the INA (8 U.S.C. 1182(d)(5)) [parole status].
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Threat to life or freedom under §243(h) of INA. A noncitizen who is lawfully present if the U.S. as a result of the
Attorney General’s withholding deportation under §243(h) of the INA (8 U.S.C. 1253(h)) [threat to life or freedom].
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Amnesty under §245A of INA. A noncitizen lawfully admitted for temporary or permanent residence under §245A
of the INA (8 U.S.C. 12555a) [amnesty granted under INA 245A].
Instructions to Housing Authority: Following verification of status claimed by persons declaring eligible immigration
status (other than for noncitizens age 62 or older and receiving assistance on June 19, 1995), HA must enter INS/SAVE
Verification Number and date that it was obtained. A HA signature is not required.
Instructions to Family Member for Completing Form: On opposite page, print or type first name, middle initial(s), and
last name. Place an “X” or “P P ” in the appropriate boxes. Sign and date at bottom of page. Place an “X” or “P P ” in the box
below the signature if the signature is by the adult residing in the unit who is responsible for Child.
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