1350 STATE OF SOUTH CAROLINA ABL-577 DEPARTMENT OF REVENUE (Rev. 9/29/08) 4367 VERIFICATION OF LAWFUL PRESENCE IN THE UNITED STATES FOR INTERNAL USE ONLY ) ) ) STATE OF SOUTH CAROLINA COUNTY OF Case Verification Number Result Pursuant to the provisions of the South Carolina Illegal Immigration Reform Act, S.C. Code Ann. Section 8-29-10, et seq., every agency of this State shall verify the lawful presence in the United States of any alien 18 years of age or older who has applied for state or local public benefits. The undersigned of (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 , (Home Address) 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. Other (Explain): Date of Birth Alien Registration Number (MUST ATTACH COPY OF IMMIGRATION DOCUMENTS) I UNDERSTAND AND ACKNOWLEDGE that a person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit executed pursuant to South Carolina Code Section 8-29-10 entitled Verification of Lawful Presence shall in addition to other sanctions imposed by this state or the United States, be guilty of a felony and upon conviction must be fined and/or imprisoned for not more than 5 years (or both). I UNDERSTAND AND ACKNOWLEDGE that any person who fails to execute this Affidavit will automatically be denied the license to which it applies. That further, the representations made in this Affidavit shall continue throughout the license period and any subsequent renewals; and I understand and agree to notify the Department of any change of my legal status as a U.S. citizen, legal permanent resident or alien lawfully present in the United States. Under of penalty of perjury, I hereby 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) ) 43671023 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. 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