1350 STATE OF SOUTH CAROLINA ABL-920 DEPARTMENT OF REVENUE (Rev. 5/15/09) 4382 VERIFICATION OF LAWFUL BACKGROUND FOR APPLICANT’S PRINCIPAL STATE OF ) ) ) COUNTY OF FOR INTERNAL USE ONLY Case Verification Number Result Pursuant to the provisions of South Carolina Code Ann. Sections 61-2-90; 61-2-100; 61-4-520; 61-6-20; 61-6-110; 61-6-1820 every principal that is an individual must submit the following information: The undersigned of , (Home Address) (Print clearly First, Middle and Last name) being first duly sworn deposes and states as follows: (City, State and Zip Code) Name Change/ Alias: Yes No If yes, please list: Check ONLY One Box: See reverse side for Instructions, Definitions, and Accepted Documents. I am a United States Citizen eighteen years of age or older. I am a Legal Permanent Resident eighteen years of age or older. I am a Qualified Alien under the Federal Immigration and Nationality Act, Public Law 82-44, eighteen years of age or older, and lawfully present in the United States. I am a Foreign Citizen, and resident of and reside at (Street Address) (Country of Residency) , (City, State, and Zip Code) Other (Explain): Date of Birth Alien Registration Number (MUST ATTACH COPY OF IMMIGRATION DOCUMENTS) I UNDERSTAND AND ACKNOWLEDGE that any person who fails to execute this Affidavit will automatically be denied the license to which it applies; and further, that the representations made in this Affidavit shall apply throughout any license(s) or renewals issued; and further, that I shall have an affirmative duty to immediately advise the Department of Revenue in any change of my immigration or citizenship status. Recognizing that I am subject to the criminal and civil penalties imposed by Title 12, of the South Carolina Code of Laws, I declare that I have examined this Affidavit and to the best of my knowledge and belief, it is true, correct and complete. Signature of Affiant REQUIRED: Fill out completely. SWORN to and subscribed before me this day of Notary Public for , year of License Number: Business Name: My Commission Expires: Notary (L.S.) Contact Person: Notary (printed name) Contact Person Phone Number: ( (Name) ) 43821024 American LegalNet, Inc. www.FormsWorkFlow.com Check box 1 – If you are a US Citizen by birth or naturalization. Check box 2 – If you are a legal permanent resident and you are not a US citizen, but are residing in the US under legally recognized and lawfully recorded permanent residence as an immigrant. PROVIDE A COPY OF ALL IMMIGRATION DOCUMENTS. Check box 3 – If you are a qualified alien. You are a qualified alien if you are: • an alien who is lawfully admitted for permanent residence under the INA; • an alien who is granted asylum under Section 208 of the INA; • a refugee who is admitted to the United States under Section 207 of the INA; • an alien who is paroled into the United States under Section 212(d)(5) of the INA for a period of at least 1 year; • an alien whose deportation is being withheld under Section 243(h) of the INA (as in effect prior to April 1, 1997) or whose removal has been withheld under Section 241(b)(3); • an alien who is granted conditional entry pursuant to Section 203(a)(7) of the INA as in effect prior to April 1, 1980; • an alien who is a Cuban/Haitian Entrant as defined by Section 501(e) of the Refugee Education Assistance Act of 1980; • an alien who has been battered or subjected to extreme cruelty, or whose child or parent has been battered or subject to extreme cruelty. PROVIDE A COPY OF ALL IMMIGRATION DOCUMENTS. Check box 4 – If you are a non immigrant and you are an alien who seeks temporary entry to the US for a specific purpose. The alien must have a permanent residence abroad (for most classes of admission) and qualify for the nonimmigrant classification sought. The nonimmigrant classifications include: foreign government officials, visitors for business and for pleasure, aliens in transit through the US, treaty traders and investors, students, international representatives, temporary workers and trainees, representatives of foreign information media, exchange visitors, fiancé(e)s of US citizens, intracompany transferees, NATO officials, religious workers, and some others. Most nonimmigrant can be accompanied or joined by spouses and unmarried minors (or dependent) children. PROVIDE A COPY OF ALL IMMIGRATION DOCUMENTS. Accepted Immigration documents: Unexpired Foreign passport with I-551 stamp or attached INS Form I-94 indicating unexpired employment authorization Alien Registration Receipt Card with photograph (INS Form I-151 or I-551) Unexpired Temporary Resident Card (INS Form I-688) Unexpired Employment Authorization Card (INS Form I-688) Unexpired Reentry Permit (INS Form I-327) Unexpired Refugee Travel Document (INS Form I-571) Unexpired Employment Authorization Document issued by the INS which contains a photograph (INS Form I-688B) American LegalNet, Inc. www.FormsWorkFlow.com