EXHIBIT C CITIZENSHIP - PERMANENT RESIDENCY VERIFICATION.PDF

EXHIBIT C
INSTRUCTIONS FOR VERIFYING CITIZENSHIP AND NON-CITIZEN LEGAL PERMANENT RESIDENT
(LPR) STATUS
Definition of U.S. Citizenship
U.S. citizenship is established at birth when an applicant is born in the U.S., its territories, or possessions. U.S.
territories or possessions include any of the following:
American Samoa
Guam - on or after January 17, 1917
Northern Mariana Islands-on or after November 4, 1986
Panama Canal Zone –on or after February 26, 1904
Puerto Rico - on or after July 1st, 2010 (Senate Bill 1182, Law #191 of 2009)
Swain Islands
U.S. Virgin Islands - on or after January 17, 1917
Verification of U.S. Citizenship
TO BE POTENTIALLY ELIGIBLE APPLICANTS WHO DECLARE U.S. CITIZENSHIP OR LEGAL RESIDENT
STATUS MUST PROVIDE DOCUMENTATION FOR VERIFYING, WITH THE FOLLOWING EXCEPTIONS:

The following participants are exempt if they are receiving the following services:
 Currently receiving Social Security Disability (SSD)...
Currently receiving Supplemental Security Income (SSI). This includes participants who move
here from another state and are in the process of transferring their SSI benefits to Arizona.
Currently receiving Medicare (g).
Eligible in the Deemed Newborn MA category.
Children in Foster Care assisted under title IV-8 of the Social Security Act. Children who are
recipients of Foster Care maintenance or adoption assistance payments under title IV-e.
Children receiving adoption subsidies.
Note: The participants receiving the service must provide an award letter or documentation as proof
of receiving the service. Once the participant is no longer receiving the benefits that meet the
exemption criteria they must then provide the proper and approved documentation as described in the
section below.

Approved Documentation
Citizenship may be verified using ANY of the documents indicated under sections A, B, C or D immediately
below:
A. Primary–Verification Documents
1. A birth certificate showing birth in the U.S., its territories or possessions.
2. Certificate of Birth issued by the Department of State (FS-545 or DPS-1350).
3. U.S. Passport current or expired, except limited passports which are issued for periods of less than 5 years.
4. U.S. Passport Card issued by the United States Citizenship and Immigration Services(USCIS).
5. Certificate of Naturalization (N-550 or N-570).
6. Certificate of U.S. Citizenship (N-560 or N-561).
7. Report of Birth Abroad of a U.S. Citizen (FS-240) issued by the U.S. State Department.
8. U.S. Consular officer's statement.
9. A United States Citizen Identification Card (I-197).
10. Northern Mariana Identification Card (I-873).
11.A tribal enrollment card or Certificate of Indian Blood issued by a federally recognized Indian Tribe that
shows that the person is enrolled or affiliated with that tribe.
12.American Indian Card (I-872) issued by USCIS with the classification code KIC. The benefit granting Service
Provider shall require the applicant to present a membership card or other tribal document demonstrating
membership in an Indian tribe. If the applicant has no document evidencing tribal membership, the benefit
granting Service Provider should contact the Indian tribe for verification of membership.

B. Secondary – Verification Documents
1. An identification card for use of Resident Citizen (I-179).
2. U.S. Census record that shows the applicant's name, a U.S. place of birth and the date of birth or the
applicant's age when the record was made. It must also indicate a place of birth in the U.S., its Territories or
Possessions.
3. Religious record created within three months after birth, showing the participant's date of birth, OR the
participant's age when the record was made. It must indicate a place of birth in the U.S. Territories or
Possessions.
4. Proof of employment as a U.S. Government Civil Servant before June 1, 1976.
5. Early school records, showing the date of admission, the child's date and place of birth and the names and
places of birth of the parents.
6. Adoption finalization papers showing the child's name and place of birth in the U.S., its territories or
possessions. (When adoption is not finalized and the State will not release a birth certificate prior to final
adoption, a statement from a state approved adoption Service Provider containing the child's name and place of
birth may be used. The source of information must be an original birth certificate and must be indicated in the
statement).
C. Primary or Secondary Documents Are Not Available
When none of the primary or secondary documents are available, accept any other document that establishes a
U.S. place of birth or in some way indicates U.S. Citizenship. These include the following:
1. Certificates of Live Birth signed by a hospital official and parent
2. Medical records created at least five years before applying for services that list a U.S. place of birth (For
children under age 16 the documents must be created near the time of birth OR five years prior to the
application date. These include: hospital wrist bands, crib cards, or yellow copies of hospital birth certificates
indicating birth in the U.S., its territories or possessions (See U.S. Citizenship on page 1).)
3. American Indian Census Records
4. Verification from the U.S. Citizenship and Immigration Services (USCIS). (The documentation CANNOT be
expired.)
5. Verification from the Social Security Administration, e.g. award letter
6. Verification sent directly to the agency from a local, state or federal bureau of vital records office

7. Legal records showing the applicant’s name and place of birth in the U.S., its territories or possessions
8. Department of Homeland Security (DHS), Verification Information System (VIS) response that validates U.S.
Citizenship
9. Online data match screen print with the Arizona Department of Vital Records through the AHCCCS
Citizenship Verification System
10. Military papers - When verifying military service criteria, the following apply:
An honorably discharged veteran of the Armed Forces of the U.S. must present an original or
notarized copy of the veteran’s discharge papers
Verify active duty status with an original or notarized copy of the applicant’s current orders or a
military ID card (DD form 2(active))
A spouse or unwed dependent child of a veteran or active duty non-citizen must provide a
document to verify relationship along with military verification requirements
A stepchild living with the stepparent must provide documents to verify relationship along with
military verification requirements
11. Marriage certificate showing marriage to a U.S. male citizen before September 22, 1922
12. Life, health or other insurance record, created at least five years before the application date (Record must
indicate a place of birth in the United States)
13. State census records that show the participant’s name, a U.S. place of birth, and the date of birth or age of
the participant
14. Tribal census records for the Navajo or Seneca tribes (The records must be created at least five years
before the application and list a U.S. place of birth.)
15. An official notification of birth registration from a U.S. State’s Department of Vital Statistics
16. An amended U.S. public birth record that is amended more than five years from the applicant’s birth
17. A statement signed by the physician or midwife who was in attendance at the time of birth
18. The roll of Alaska Natives from the Bureau of Indian Affairs
19. A current decision letter from the ADES/Family Assistance Administration that demonstrates eligibility for
the Food Stamp or Cash Assistance Programs (The award letter must list the Low Income Home Energy
Assistance Program (LIHEAP) applicant as an eligible member of the household and for Short Term Crisis
Services (STCS) Program the qualifying child must be listed as an eligible member of the household.)

D. Primary or Secondary Documents Not Obtainable
When the applicant cannot obtain the Primary or Secondary forms of verification they may provide an Affidavit
Attesting Citizenship. An Affidavit Attesting Citizenship must meet all of the following requirements:
1. Be completed by a U.S. Citizen who is knowledgeable about the participant’s circumstances
2. Be signed by a U.S. Citizen that is not a member of the household
3. Be approved by the Case Manager Supervisor
4. Document the reason for using the affidavit form
Acceptable Copies
Only original or un-tampered copies of required documents are acceptable for verifying citizenship.
Verification of Qualified Non-Citizens
Qualified Non-Citizen Categories
Applicants, who state they are Non-Citizen Legal Residents, must meet at least one of the categories set forth
immediately below:
A. Lawful Permanent Resident (LPR)
A lawful permanent resident (LPR) is admitted into the U.S. for permanent residence under the Immigration and
Nationality Act (INA). This Non-Citizen Legal Resident is potentially eligible for services when they meet any of
the following:
1) They have been continuously lawfully residing in the U.S. and their date of entry is five years in the
past or more
2) They entered the U.S. as a Non-Citizen Legal Resident eligible for benefits in another qualified
category prior to becoming an LPR
3) They have a military connection
4) They are American Indians born in Canada who possess at least 50 per centum of American Indian
Blood. These Non-Citizen Legal Residents are recognized as LPR
These applicants normally have one of the following USCIS documents.
(NOT ACCEPTABLE IFDOCUMENTS ARE EXPIRED):
1) I-551- Resident Alien Card (Eligible for Benefits)
2) I-151- Alien Registration Receipt Card (Eligible for Benefits)

3) I-194- or unexpired passport with the words: Processed for I-551
Temporary Evidence of Lawful Permanent Residence. Valid Until (Date)
With the following Stamp/Annotations of Law
1) Adjustment Admission Stamp - Eligible when any of the following sections of law are indicated:
203(a)(7); 207;208;212(d)(5); 243(h)(with a PRUCOL determination)
2) Non-Specific Admission Stamp -Eligible when the form is noted with an I- 551 eligible status code
3) Parole Admission Stamp - Eligible when the period of parole is for at least one year as verified on the
stamp
4) Replacement Admission Stamp - Eligible when the stamp displays an I-551 eligible Status Code
5) Temporary I-551 Admission Stamp - Eligible when the key phrase reads one of the following:
a) "Admission for Permanent Residence at: “D" or "Processed for I-551 Temporary evidence of
admission for Permanent Residence" and displays one of the following Status Codes: AM1; -2; -
3; -6; -7; -8,
b) Asylee
An Asylee, Non-Citizen Legal Resident is granted asylum through an exercise of discretion by
the Attorney General, pursuant to Section 208 of INA. This Non-Citizen is potentially eligible for
benefits for a period of seven years from the date their status is granted.
Note: The eligibility period begins from the month the Asylee status is granted, NOT the
month of U.S. entry.
These applicants normally have one of the following USCIS documents.
(NOT ACCEPTABLE IFDOCUMENTSARE EXPIRED):

I-94 with one of the following:
A stamp showing grant of asylum under Section 208 of the INA to include:
A. AS1 - Eligible for benefits
B. AS2 - Eligible for benefits
C. AS3V92 - Eligible for benefits

Refugee or Amerasian
A Refugee or Amerasian is admitted into the U.S. under Section 207 of INA. This Non-Citizen is potentially
eligible for benefits for a period of seven years from the date that their status is granted.
These applicants normally have one of the following USCIS documents.
(NOT ACCEPTABLE IFDOCUMENTSARE EXPIRED):
I-94- endorsed to show entry as a refugee under Section 207 of the INA or entry as an Amerasian OR noted
with one of the following Status Codes: NP2 - 7; P2 -6, -7, -71; RE-8; Z2; (Eligible for Benefits).
Victim of Human Trafficking
.A victim of human trafficking is admitted onto the U.S. under the Trafficking Victims Protection Act (TVPA) of
2000. This Non-Citizen Legal Resident is potentially eligible for services for a period of seven years from the
date that their status is granted. These applicants normally have one of the following USCIS documents:
I-94- with a T Visa or Derivative T Visa (T, T-2, T-3, T-4, or T-5)
(NOT ACCEPTABLE IF DOCUMENTS ARE EXPIRED).
Non-Citizen Legal Resident Paroled Into The U.S.
A Non-Citizen paroled into the U.S. is lawfully present in the U.S. as a result of a grant of parole by the Attorney
General, pursuant to Section 212(d) (5) of the INA. This Non-Citizen is potentially eligible for services when the
period of the parole is for at least one year. These applicants normally have one of the following USCIS
documents (NOT ACCEPTABLE IF DOCUMENTS ARE EXPIRED):

I-94 - with PAROLE PURSUANT TO SECTION 212(d) (5) on the front.
The form must not be expired and the expiration date must be at least one year after the issue date. Both dates
are documented on the form (Eligible for Benefits).
Non-Citizen Legal Resident Whose Deportation Is Withheld
A Non-Citizen Legal Resident whose deportation is withheld is a Non-Citizen Legal Resident for whom the
Attorney General has withheld deportation from the U.S. pursuant to Section 243(h) or 241 (b)(3) of the INA. A
Non-Citizen Legal Resident whose deportation is withheld is potentially eligible for services for a period of seven
years from the date of the judge's orders.
These applicants normally have one of the following USCIS documents:
(NOT ACCEPTABLE IFDOCUMENTSARE EXPIRED).

I-94 -with an order from an immigration Judge showing one of the following:

 Deportation withheld under 243(h) of the INA (Eligible for Benefits)
 Removal withheld under 241(b)(3) of the INA (Eligible for Benefits)
Cuban or Haitian Entrant
Cuban or Haitian entrants are admitted to the U.S. by USCIS as a Cuban or Haitian entrant
pursuant to Section 501 (e) of the Refugee Education Assistance Act of 1980 (PL 104-93).
Cuban or Haitian entrants are potentially eligible for benefits for a period of seven years
from the date that their status is granted.
These applicants normally have the following USCIS document:
(NOTACCEPTABLE IFDOCUMENTS ARE EXPIRED)
 I-94 with the words: CUBAN/HAITIAN ENTRANT UNDER 212(D) OF THE
INA (Eligible for Benefits)
Conditional Entrant
A conditional entrant was granted conditional entry into the U.S. before April 1, 1980,
pursuant to Section 203 (a) (7) of the INA. Conditional entrants are potentially eligible for
benefits regardless of any later change in their status.
These applicants normally have one of the following USCIS documents.
(NOT ACCEPTABLE IF DOCUMENTS ARE EXPIRED):
 I-94 – with the words: ADMITTED AS A REFUGEE – CONDITIONAL ENTRY
under Section 203(a) (7) of the INA. (Eligible for Benefits)
Abused or Battered Non-Citizen
Documented Non-Citizens may become qualified Non-Citizens when they have suffered
abuse from a parent or a spouse.
The Service Provider staff must informthe Abused or Battered applicant of the following:
1. Applicant must contact the USCIS to obtain a Petition for Abused Aliens
2. The abuse must have occurred in the U.S. and the abusive person must be a U.S.
Citizen or Lawful Permanent Resident
3. They must currently reside in the U.S.
4. They must provide any and all documentation verifying continuous residency in the
U.S. for the prior five years
Note: All periods of time that are not accounted for must be addressed by an applicant
statement.

In order for the Non-Citizen to be eligible under this category, they must meet ALL of the
following:
1. Possess appropriate USCIS status
2. Be battered or subject to extreme cruelty
3. Have a substantial connection between battery and the need for benefits
4. No longer residing with the batterer
Indefinite Detainee
Indefinite detention status pertains to Non-Citizens who have served their time for a criminal
conviction and have been given formal orders to leave the U.S. Subsequently, Indefinite
Detainee status is met when the Non-Citizen is allowed to indefinitely remain the U.S.
because neither their home country, nor any other country will accept them.
Military Connection
Non-Citizens who meet both of the following criteria are potentially eligible for benefits,
regardless of their date of entry:
1. They are a qualified Non-Citizen
2. They meet one of the following military service criteria:
A. An honorably discharged veteran or person on active duty
B. On active duty in the Armed Forces of the U.S.
C. A spouse of a veteran or person on active duty who meets one of the following:
a) Is legally married to the veteran or person on active duty
b) Is legally separated from the veteran or person on active duty
c) Is a widowed spouse of the veteran or person on active duty and has not
remarried
Note: The applicant remains eligible regardless of whether they are living together or apart;
the veteran or active duty person can be a U.S. Citizen or a Non-Citizen Legal Resident
When verifying military service criteria, the following apply:
3. An honorably discharged veteran of the Armed Forces of the U.S. must present an
original or notarized copy of the veteran's discharge papers
4. To verify the active duty status an original or notarized copy of the applicant's
current orders or a military ID card (DD form 2 (active)) may be used

5. Only full-time Air Force, Army, Navy, Marine or Coast Guard is eligible
6. Any Reserve or National Guard duty is excluded
A spouse or single dependent child of a veteran or active duty alien must provide a document
to verify relationship along with military verification requirements.
Non-Citizen Alien Identification Cards
This section identifies alien ID cards that applicants may provide to determine
whether they meet one of the qualified non-citizen requirements to receive benefits.
Documents cannot be EXPIRED.
I. Alien Identification Cards
The eligible ID cards listed in this section are as follows:
1. I-94 Arrival/Departure Record
2. POTENTIALLY ELIGIBLE depending on the following:
 I-94 admission stamp used, section of law/class-code annotations; Applicant must also meet a
qualified Non-Citizen Legal Resident Status criteria identified in Section II-A. NOT ELIGIBLE for
benefits when the document lacks a registration number
a. I-94 Parole Edition
POTENTIALLY ELIGIBLE depending on the following:
I-94 admission stamp used; section of law/class-code annotations; Applicant must
also meet a qualified Non-Citizen Legal Resident Status criteria identified in Section
II-A. NOT ELIGIBLE for benefits when the document lacks a registration number.
b. I-151 Alien Registration Card
POTENTIALLY ELIGIBLE -The I-151 is the original green card. Many however
were printed on blue paper; several versions of this card exist.
Applicants must also meet qualified Non-Citizen Legal Resident Status criteria
identified in Section II-A.
c. I-551 Permanent Resident Card
d. Visa Stamps in Foreign Passports- Eligible when all of the following occur:

I. The Visa is stamped "Processed for I-551, temporary Evidence of Lawful Admission for
Permanent Residence".
II. Neither the Visa NOR the passport have expired. The passport's expiration date is normally
found on the same page as the person's photograph.
Note: Applicants, who have expired, lost or otherwise cannot locate their immigration documents from USCIS
are responsible for contacting USCIS for replacement documents.
Note: Qualified Non-Citizen Legal Residents may have documents described as eligible; Case Managers must
examine documents to establish their expiration date and cannot accept expired documents.
Affidavit That Document(s) Is/Are True
An eligible applicant must execute a sworn affidavit (see Exhibit IV) stating that the documentation provided as
listed on this document during the verification process is/are true.
1. Contractors who determine eligibility for these programs will be required to ensure that a sworn
affidavit is obtained in a way that does not delay the eligibility determination process, or add cost to
the process for the applicant.
2. Eligible applicants are exempt from providing an affidavit only if they are 60 years of age or older, if
they are Tribal Members or if they are disabled or have an incapacity of the body or mind which
makes them unable to supply suchaffirmation.
3. Any contractor classified as a non-profit charitable organization must notify Department of Economic
Security, Division of Aging and Adult Services (DES/DAAS), if "discovered violations" will not be
reported to ICE, also:
A. Contractors will establish their own process for reporting discovered violations to
the Federal Department of Immigration and Customs Enforcement (ICE) and are advised
to consult with legal counsel or ICE for further guidance.
Determining Non-citizen Status
To determine non-citizen status, complete the following:
1. Ask the applicant for their USCIS documentation. When the applicant states they do not have documentation,
do not question the participant further regarding their non-citizen status.
2. When the document is provided, compare the document to the documents listed on pages 4 through 10. If the
document is one of the qualified non-citizen documents, the non-citizen has a qualified status.

3. A nonqualified non-citizen, who is residing in the United States without the knowledge or permission of
USCIS, may do one of the following:
4. Voluntarily self-declare that they are residing in the U.S. illegally or
5. Provide Immigrations and Customs Enforcement (ICE) documents verifying violation of USCIS law.
6. When either of these occurs, follow your Service Provider's process for reporting discovered violations to the
Federal Department of Immigration and Customs Enforcement (ICE).
Non-Qualified Non-Citizens
Consider the following Non-Citizens as Non-Qualified. Documents include, but are not limited to the following:
1. I-94 (Non-citizens with this document may have either qualified or nonqualified status. The admission
stamp annotated on the card determines the non-citizen's status.)
2. I-184 (Crewman Landing Permit)
3. I-185 (Nonresident Alien Canadian Border Crossing Card)
4. I-186 (Nonresident Mexican Border Crossing Card)
5. I-444 (-Mexican Border Visitor Permit)
6. I-586 (Nonresident Alien Border Crossing Card)
7. l-688A (Employment Authorization)
8. I-688 (Temporary Resident [This is the first card issued to non-citizens living in the U.S. under the
Amnesty Program of the Immigration Reform and Control Act of 1986.])
9. I-688B (Employment Authorization [This is the second card issued to non-citizens under the Amnesty
Program of the Immigration Reform and Control Act of 1986.])
10. I-689 (Fee Receipt-Non-citizens [With this card may have either qualified or nonqualified status.
The Provision of Law annotated on the card determines the non-citizen's status.])
11. I-766 (Employment Authorization)
12. DSP150 (Border Crossing Card [This card was introduced in 1997. Non-citizens with this card may
have either qualified or nonqualified status. The Provision of Law annotated on the card determines
the non-citizen's status.])
13. Student Visa (This card was introduced in 1998)

Ineligible Alien ID Cards
When an applicant provides one of the following alien ID cards they are INELIGIBLE for services and the
applicant must provide another eligible document. All these forms expired before January 24, 1990.
1) Any alien ID cards that are expired.
2) I-181a Memorandum of creation of record of lawful permanent residence
3) I-184 Alien crewman landing permit and identification card
4) I-185 Non-resident alien Canadian border crossing card
5) I-186 Non-resident alien Mexican border crossing card
6) I-444- Mexican border visitor permit
7) I-586 Non-resident alien border crossing card
8) I-688 Employment authorization
9) I-688A Employment authorization document
10) I-688BEmployment authorization document
11) I-689 Fee receipt
12) I-766 Employment authorization document
13) Non-resident border crossing card