STATE OF CALIFORNIA DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS FOR STATE PUBLIC BENEFITS Name of Applicant/Licensee (Print Last, First and Middle Names) ABC License No(s). (Current licensees only) ( Identify all licenses you possess). What to complete Today's Date · · Citizens and nationals of the United States who meet all eligibility requirements may receive a California alcoholic beverage license and must complete Sections A and D. Aliens who meet all eligibility requirements may also receive a California alcoholic beverage license and must complete Sections A, B, C (if applicable), and D of this form. What to submit · Completed ABC-69 with original signature(s). Photocopies and fax copies are not acceptable. · Supporting document(s). See List A and B. CITIZENSHIP/IMMIGRATION STATUS DECLARATION SECTION A: 1. Is the applicant a citizen or national of the United States? If the answer to the above question is yes, where were you born? (City and State) Yes No 2. To establish citizenship or nationality, please submit a copy of one of the documents on List A (attached hereto) or a certified copy of your birth certificate which is legible and unaltered to establish proof. IF YOU ARE A CITIZEN OR NATIONAL OF THE UNITED STATES, GO DIRECTLY TO SECTION D. IF YOU ARE AN ALIEN, PLEASE COMPLETE SECTION B AND D, AND, IF NECESSARY, SECTION C. SECTION B: ALIEN STATUS DECLARATION IMPORTANT: Please indicate your alien status below, and submit copies of both sides (front and back) of the 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 the category. You can provide other acceptable evidence of your alien status even if not listed below. 1. 2. 3. 4. 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. An alien who is granted asylum under section 208 of the INA. 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. A refugee admitted to the United States under section 207 of the INA. 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). 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.) (4/03) ABC-69 - 1American LegalNet, Inc. www.FormsWorkflow.com 5. 6. 7. 8. 9. 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 s243(h) of the INA as in effect prior to April 1, 1997, or removal withheld under section 241(b)(3) of the INA. An alien who is granted conditional entry under section 203(a)(7) of the INA as in effect prior to April 1, 1980. Evidenceincludes: 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." 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. 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 "Cuba/Haitian Entrant" under section 212(d)(5) or the INA. 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.) An alien not in 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 you or your child, or your child's parent has been battered or subjected to extreme cruelty in the United States. 1. Has the INS or the Executive Office of Immigration Review (EOIR) granted a petition or application filed by or on behalf of the application, 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). Yes No 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 to the battery or cruelty)? Yes No 2. 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: Applicant's Printed Name: Applicant's Home Address: Address City Signature of Person Acting For Applicant: Printed Name of Person Acting for Applicant Street Date: ( ) Daytime Telephone Number Country State Date: ( ) Daytime Telephone Number RETURN WITH APPLICATION OR LICENSE RENEWAL NOTICE and F