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HomeMy WebLinkAbout600-030-010-R003 Moss - Certification of Lawful Presence 07-19-19OPCCertification of Lawful Presencein 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:Michael Moss46400 Dune Palms Rd., La Quinta, CASite Address: | g^gg """" ' '"""w '""'""" —"-'OPC case ID: | 600-030-010:R003Agency: | City of La Quinta! Dune Palms Road Low WaterCrossing ProjectOPC Agent: | Patti Feist, Project ManagerCertification Date;^Tu/y ? Zo/fWARNING: 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 card@ holders),C. I am an alien not lawfully present in the United States.D. I decline to provide this information.?iH0u|i|l|igld|14embeKN|me;|SftsslSf^elationSi^tizenshiBSSiBtjStaSus^SBliii&SBHSfBCTSBsB|al)ove!)5SSg;IJ8x®gBSNS8SgSignatujiffihiciM-ei Kosr31Head of Household®B C D^S^dt ^^C D^.C^WjJ ^Q(^\^^&BC DT^SLL/T^/J^1k^ ^t^A^JiifA^) B C D0\/\A,^Lft//^\M.Mcc^fT^\1(DB C DA B C DA B C DA B C DA B C DAgency notes:©20180PC