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HomeMy WebLinkAbout600-030-010-R001 Prebot-Robles - Cert of Lawful Presence 06-17-19AOPCCertification of Lawful Presence in the U.S.INSTRUCTIONS: Pursuant to the Public Law 105-117 of 11-21-97, in order to be eligible to receive relocation benefits in federally-fundedrelocation projects, all members of the household to be displaced must provide information regarding their lawful presence in the UnitedStates. The Head of Household or other responsible adult must certify for minors under 18 years of age. Any member of the householdwho is not lawfully present in the United States, or who declines to provide this information, may be denied relocation benefits,Claimant:Site Address:OPC case ID:Alejandro Prebot & Hilda Robles46400 Dunes Palms Rd., #31La Quinta, CA 92253600-030-010:R001Agency: | City of La QuintaProject:OPC Agent:Dune Palms Road Low WaterCrossing Bridge ProjectPatti FeistCertification Date: (f} - / 7-/c/~TWARNING: If you knowingly or deliberately make false, misleading or fraudulentstatements on this form you may be subject to civil and criminal penalties including finesand imprisonment, under Section 1001 of Title 18 of the United States Code.I CERTIFY, under the penalty of perjury, to the best of my knowledge, to the following lawful presence status:A. I am a citizen (including natural ized citizens) or national of the United States.B. I am an alien lawfully present in the United States (including Agreen carde holders).C. I am an alien not lawfully present in the United States.D. I decline to provide this information.No.123456789Household Member Name14,1^ ^kl^Age^L_RelationHead of HouseholdCitizenship Status(circle one from listabove)^ B C DA B C DA B C DA B C DA B C DA B C DA B C DA B C DA B C DSignaturem^< -^MuAgency notes: "^fL^.cd ^Lt( ^^' jl A ./^V ^ W-K / ^y^-^^ ^^©2018 OPC Certificate of Lawful Presence in the U.S.INSTRUCTIONS: Pursuant to the Public Law 105-117 of 11-21-97, in order to be eligible to receive relocationbenefits in federally-funded relocation projects, all members of the household to be displaced must provideinformation regarding their lawful presence in the United States. The Head of Household or other responsibleadult must certify for minors under 18 years of age. Any member of the household who is not lawfullypresent in the United States, or who declines to provide this information, may be denied relocationbenefits.IClaimant: | Alejandro Prebot & Hilda RoblesSite Address:46400 Dune Palms Rd. # 31La Quinta CA 92253OPC case ID: | 600-030-010:R001Agency: | The City of La QuintaDune Palms Road Low WaterCrossing ProjectConsultant: I Patti FeistCertification Date:^ / 7 -/^GWARNING: If you knowingly or deliberately make false, misleading or fraudulentstatements on this form you may be subject to civil and criminal penalties including finesand imprisonment, under Section 1001 of Title 18 of the United States Code.I CERTIFY, under the penalty of perjury, to the best of my knowledge, to the following lawful presence status:A. I am a citizen (including naturalized citizens) or national of the United States.B. I am an alien lawfully present in the United States (including Agreen cards holders).C. I am an alien not lawfully present in the United States.D. I decline to provide this information.No12345678Name of HouseholdMemberAlejandro PrebotHilda RoblesVanessa BedollaMarco BedollaAge^5Yzo^_RelationHead of /4d^.Household•Sc (^^' i^h ^-S^ >]Citizenship Status(circle one fromlist above)^_^_@AAAAABBB/£BBBBccccccccDDDDDDDDSignature^^^L^:€^-/^ ^—Agency notes: