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HomeMy WebLinkAbout600-030-010-Roo4 Chin Family - Certificate of Lawful Presence - Business© 2018 OPC Certification of Lawful Presence in the U.S. Non-Residential INSTRUCTIONS: Pursuant to the Public Law 105-117 of 11-21-97, in order to be eligible to receive relocation benefits in federally-funded relocation projects, a business, as a displaced person, must provide information regarding its lawful presence in the United States. A duly authorized representative of the business must make this certification. Any Business/Displaced Person, who is not lawfully present in the United States, or who declines to provide this information, may be denied relocation benefits. Claimant: Chin Family Properties Limited Partnership Agency: City of La Quinta Site Address: 46400 Dune Palms Road, La Quinta, CA 92253 Project: Dune Palms Road Bridge Project OPC case ID: 600-030-010 R:004 Agent: Patti Feist Certification Date: ________________________________ WARNING: If you knowingly or deliberately make false, misleading or fraudulent statements on this form you may be subject to civil and criminal penalties including fines and imprisonment, under Section 1001 of Title 18 of the United States Code. Business type: [ ] Corporation [ ] Sole Proprietorship [ ] Partnership I CERTIFY, under the penalty of perjury, to the best of my knowledge, to the following lawful presence status: A. I am a citizen or national of the United States, or an alien who is lawfully present in the United States. B The Corporation is authorized to conduct business in the United States. C I am an alien not lawfully present in the United States. D I decline to provide this information. No. Owner/Officer Name % Interest Title Citizenship Status (circle one from list above) Signature 1 A B C D 2 A B C D 3 A B C D 4 A B C D 5 A B C D 6 A B C D 7 A B C D 8 A B C D 9 A B C D Agency notes: _____________________________________________________________________________