Cal. Code Regs. tit. 8 § 15741
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRAIL RELATIONS
UNINSURED EMPLOYERS FUND-SUBSEQUENT INJURIES FUND
STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS FOR STATE PUBLIC
BENEFITS
| Name of Applicant (the person seeking Uninsured Employers Fund or Subsequent Injuries Fund benefits) | Date |
| Name of Person Acting for Applicant, if any | Relationship to Applicant |
STATE PUBLIC BENEFITS TO CITIZENS AND ALIENS
Citizens and nationals of the United States who meet all eligibility requirements may receive Uninsured Employers Fund or Subsequent Injuries Fund benefits and must fill out Sections A and D.
Aliens who meet all eligibility requirements may also receive Uninsured Employers Fund or Subsequent Injuries Fund benefits and must complete SECTIONS A, B, C and D of this form.
If the answer to the above question is yes, where was he/she born? ___________________________________ (State or Country)
IF YOU ARE A CITIZEN OR NATIONAL OF THE UNITED STATES, GO DIRECTLY TO SECTION D. IF YOU ARE AN ALIEN, PLEASE COMPLETE SECTION B, AND, IF NECESSARY, SECTION C.
IMPORTANT: Please indicate the applicant's alien status below, and submit documents evidencing such status. The alien status documents listed for each category are the most commonly used documents that the United States Immigration and Naturalization Service (INS) provides to aliens in those categories. You can provide other acceptable evidence of your alien status even if not listed below. Where authorized by the INS, the documents you provide will be submitted to the INS for verification through the Systematic Alien Verification for Entitlements ("SAVE") system. Should verification through the "SAVE" system be unavailable, the validity of the documents you provide may be verified directly with the issuing government agency.
| 1. | An alien lawfully admitted for permanent residence under the Immigration and Naturalization Act (INA). (Evidence includes: | [] | |
| * | INS Form I-1551 (Alien Registration Receipt Card, commonly known as a "green card"); or | ||
| * | Unexpired Temporary I-551 stamp in foreign passport or on INS Form I-94). | ||
| 2. | An alien who is granted asylum under section 208 of the INA. (Evidence includes: | [] | |
| * | INS Form I-94 annotated with stamp showing grant of asylum under section 208 of the INA; | ||
| * | INS Form I-688B (Employment Authorization Card) annotated "274a.12(a)(5)"; | ||
| * | INS Form I-766 (Employment Authorization Document) annotated "A5"; | ||
| * | Grant letter from the Asylum Office of INS; or | ||
| * | Order of an immigration judge granting asylum.) | ||
| 3. | A refugee admitted to the United States under section 207 of the INA. (Evidence includes: | [] | |
| * | INS Form I-94 annotated with stamp showing admission under s 207 of the INA; | ||
| * | INS Form I-688B (Employment Authorization Card) annotated "274a.12(a)(3)"; | ||
| * | INS Form I-766 (Employment Authorization Document) annotated "A3"; or | ||
| * | INS Form I-571 (Refugee Travel Document). | ||
| 4. | An alien paroled into the United States for at least one year under section 212(d)(5) of the INA. (Evidence includes: | [] | |
| * | INS Form I-94 with stamp showing admission for at least one year under section 212(d)(5) of the INA. (Applicant cannot aggregate periods of admission for less than one year to meet the one-year requirement.) | ||
| 5. | An alien whose deportation is being withheld under section 243(h) of the INA (as in effect immediately prior to September 30, 1996) or Section 241(b)(3) of such Act (as amended by section 305(a) of division C of Public Law 104-208). (Evidence includes: | [] | |
| * | INS Form I-688B (Employment Authorization Card) annotated "274a.12(a)(10)"; | ||
| * | INS Form I-766 (Employment Authorization Document) annotated "A10"; or | ||
| * | Order from an immigration judge showing deportation withheld under s 243(h) of the INA as in effect prior to April 1, 1997, or removal withheld under s 241(b)(3) of the INA.) | ||
| 6. | An alien who is granted conditional entry under section 203(a)(7) of the INA as in effect prior to April 1, 1980. (Evidence includes: | [] | |
| * | INS Form I-94 with stamp showing admission under s 203(a)(7) of the INA; | ||
| * | INS Form I-688B (Employment Authorization Card) annotated "274a.12(a)(3)"; or | ||
| * | INS Form I-766 (Employment Authorization Document) annotated "A3"). | ||
| 7. | An alien who is a Cuban or Haitian entrant (as defined in section 501(e) of the Refugee Education Assistance Act of 1980). (Evidence includes: | [] | |
| * | INS Form I-551 (Alien Registration Receipt Card, commonly known as a "green card") with the code CU6, CU7, or CH6; | ||
| * | Unexpired temporary I-551 stamp in foreign passport or on INS Form I-94 with the code CU6 or CU7; or | ||
| * | INS Form I-94 with stamp showing parole as "Cuba/Haitian Entrant" under Section 212(d)(5) of the INA.) | ||
| 8. | An alien paroled into the United States for less than one year under section 212(d)(5) of the INA. (Evidence includes INS Form I-94 showing this status.) | [] | |
| 9. | An alien not in categories 1 through 8 who has been admitted to the United States for a limited period of time (a non-immigrant). Non-immigrants are persons who have temporary status for a specific purpose. (Evidence includes INS Form I-94 showing this status.) | ||
IMPORTANT: Complete this section if the applicant, the applicant's child or the applicant child's parent has been battered or subjected to extreme cruelty in the United States.
| 1. | Has the INS or the EOIR granted a petition or application filed by or on behalf of the applicant, the applicant's child, or the applicant's child's parent under the INA or found that a pending petition sets forth a prima facie case? Evidence includes one of the documents on List B (attached hereto) | [] |
| 2. | Has the applicant, the applicant's child, or the applicant child's parent been battered or subjected to extreme cruelty in the United States by a spouse or parent, or by a spouse's or parent's family member living in the same house (where the spouse or parent consented to, or acquiesced in the battery or cruelty)? | [] |
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE ANSWERS I HAVE GIVEN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Applicant's Signature: ________________________________________Date:__________________
Signature of Person Acting for Applicant: ________________________________________ Date:__________________
LIST "A"
(For Applicants for Uninsured Employers Fund or Subsequent Injuries Fund benefits who are citizens or nationals of the United States.)
* A birth certificate showing birth in one of the 50 States, the District of Columbia, Puerto Rico (on or after January 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917), American Samoa, Swain's Island or the Northern Mariana Islands, unless the person was born to foreign diplomats residing in the U.S.
Note: If the document shows that the individual was born in Puerto Rico, the U.S. Virgin Islands or the Northern Mariana Islands before these areas became part of the U.S., the individual may be a collectively naturalized citizen-(see Paragraph C below).
* United States passport (except limited passports, which are issued for periods of less than five years);
* Report of birth abroad of a U.S. citizen (FS-240) (issued by the Department of State to U.S. citizens);
* Certificate of birth (FS-545) (issued by a foreign service post) or Certification of Report of Birth (DS-1350) (issued by the Department of State), copies of which are available from the Department of State;
* Certificate of Naturalization (N-550 or N-570) (issued by the INS through a Federal or State court, or through administrative naturalization after December 1990 to individuals who are individually naturalized; the N-570 is a replacement certificate issued when the N-550 has been lost or mutilated or the individual's name has been changed);
* Certificate of Citizenship (N-560 or N-561) (issued by the INS to individuals who derive U.S. citizenship through a parent; the N-561 is a replacement certificate issued when the N-560 has been lost or mutilated or the individual's name has been changed);
* United States Citizen Identification Card (I-197) (issued by the INS until April 7, 1983 to U.S. citizens living near the Canadian or Mexican border who needed it for frequent border crossings) (formerly Form I-179, last issued in February 1974);
* Northern Mariana Identification Card (issued by the INS to a collectively naturalized citizen of the U.S. who was born in the Northern Mariana Islands before November 3, 1986);
* Statement provided by a U.S. consular officer certifying that the individual is a U.S. citizen (this is given to an individual born outside the U.S. who derives citizenship through a parent but does not have an FS-240, FS-545 or DS-1350); or
* American Indian Card with a classification code "KIC" and a statement on the back (identifying U.S. citizen members of the Texas Band of Kickapoos living near the U.S./Mexican border).
If the applicant cannot present one of the documents listed in A above, the following may be relied upon to establish U.S. citizenship or nationality:
* Religious record recorded in one of the 50 States, the District of Columbia, Puerto Rico (on or after January 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917)), American Samoa, Swain's Island or the Northern Mariana Islands (unless the person was born to foreign diplomats residing in such a jurisdiction) within three months after birth showing that the birth occurred in such jurisdiction and the date of birth or the individual's age at the time the record was made;
* Evidence of civil service employment by the U.S. government before June 1, 1976;
* Early school records (preferably from the first school) showing the date of admission to the school, the child's date and place of birth, and the name(s) and place(s) of birth of the parent(s);
* Census record showing name, U.S. citizenship or a U.S. place of birth, and date of birth or age of applicant;
* Adoption Finalization Papers showing the child's name and place of birth in one of the 50 States, the District of Columbia, Puerto Rico (on or after January 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917), American Samoa, Swain's Island or the Northern Mariana Islands (unless the person was born to foreign diplomats residing in such a jurisdiction) or, where or adoption is not finalized and the State or other jurisdiction listed above in which the child was born will not release a birth certificate prior to final adoption, a statement from a state-approved adoption agency showing the child's name and place of birth in one of such jurisdictions (NOTE: the source of the information must be an original birth certificate and must be indicated in the statement); or
* Any other document that establishes a U.S. place of birth or in some way indicates U.S. citizenship (e.g., a contemporaneous hospital record of birth in that hospital in one of the 50 States, the District of Columbia, Puerto Rico (on or after January 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917), American Samoa, Swain's Island or the Northern Mariana Islands (unless the person was born to foreign diplomats residing in such a jurisdiction).
If the applicant cannot present one of the documents listed in A or B above, the following will establish U.S. citizenship for collectively naturalized individuals:
Puerto Rico:
* Evidence of birth in Puerto Rico on or after April 11, 1899 and the applicant's statement that he or she was residing in the U.S., a U.S. possession or Puerto Rico on January 13, 1941; or
* Evidence that the applicant was a Puerto Rican citizen and the applicant's statement that he or she was residing in Puerto Rico on March 1, 1917 and that he or she did not take an oath of allegiance to Spain.
U.S. Virgin Islands:
* Evidence of birth in the Virgin Islands, and the applicant's statement of residence in the U.S., a U.S. possession or the U.S. Virgin Islands on February 25, 1927;
* The applicant's statement indicating resident in the U.S. Virgin Islands as a Danish citizen on January 17, 1917 and residence in the U.S., a U.S. possession or the U.S. Virgin Islands on February 25, 1927, and that he or she did not make a declaration to maintain Danish citizenship; or
* Evidence of birth in the U.S. Virgin Islands and the applicant's statement indicating residence in the U.S., a U.S. possession or territory or the Canal Zone on June 28, 1932.
Northern Mariana Islands (NMI) (formerly part of the Trust Territory of the Pacific Islands (TTPI)):
* Evidence of birth in the NMI, TTPI citizenship and residence in the NMI, the U.S., or a U.S. territory or possession on November 3, 1986 (NMI local time) and the applicant's statement that he or she did not owe allegiance to a foreign state on November 4, 1986 (NMI local time);
* Evidence of TTPI citizenship, continuous residence in the NMI since before November 3, 1981 (NMI local time), voter registration prior to January 1, 1975 and the applicant's statement that he or she did not owe allegiance to a foreign state on November 4, 1986 (NMI local time); or
* Evidence of continuous domicile in the NMI since before January 1, 1974 and the applicant's statement that he or she did not owe allegiance to a foreign state on November 4, 1986 (NMI local time).
Note: If a person entered the NMI as a nonimmigrant and lived in the NMI since January 1, 1974, this does not constitute continuous domicile and the individual is not a U.S. citizen.
If the applicant cannot present one of the documents listed in A or B above, you should make a determination of derivative U.S. citizenship in the following situations:
Applicant born abroad to two U.S. citizen parents:
* Evidence of the U.S. citizenship of the parents and the relationship of the applicant to the parents, and evidence that at least one parent resided in the U.S. or an outlying possession prior to the applicant's birth.
Applicant born abroad to a U.S. citizen parent and a U.S. non-citizen national parent:
* Evidence that one parent is a U.S. citizen and that the other is a U.S. non-citizen national, evidence of the relationship of the applicant to the U.S. citizen parent, and evidence that the U.S. citizen parent resided in the U.S., a U.S. possession, American Samoa or Swain's Island for a period of at least one year prior to the applicant's birth.
Applicant born out of wedlock abroad to a U.S. citizen mother:
* Evidence of the U.S. citizenship of the mother, evidence of the relationship to the applicant and, for births on or before December 24, 1952, evidence that the mother resided in the U.S. prior to the applicant's birth or, for births after December 24, 1952, evidence that the mother had resided, prior to the child's birth, in the U.S. or a U.S. possession for a period of one year.
Applicant born in the Canal Zone or the Republic of Panama:
* A birth certificate showing birth in the Canal Zone on or after February 26, 1904 and before October 1, 1979 and evidence that one parent was a U.S. citizen at the time of the applicant's birth; or
* A birth certificate showing birth in the Republic of Panama on or after February 26, 1904 and before October 1, 1979 and evidence that at least one parent was a U.S. citizen and employed by the U.S. government or the Panama Railroad Company or its successor in title.
All other situations where an applicant claims to have a U.S. citizen parent and an alien parent, or claims to fall within one of the above categories but is unable to present the listed documentation:
* If the applicant is in the U.S., refer him or her to the local INS office for determination of U.S. citizenship;
* If the applicant is outside the U.S., refer him or her to the State Department for a U.S. citizenship determination.
* If the birth certificate shows a foreign place of birth and the applicant cannot be determined to be a naturalized citizen under any of the above criteria, obtain other evidence of U.S. citizenship;
* Since foreign-born adopted children do not automatically acquire U.S. citizenship by virtue of adoption by U.S. citizens, refer the applicant to the local INS district office for a determination of U.S. citizenship if the applicant provides no evidence of U.S. citizenship.
A women acquired U.S. citizenship through marriage to a U.S. citizen before September 22, 1922. Ask for: Evidence of U.S. citizenship of the husband, and evidence showing the marriage occurred before September 22, 1922.
Note: If the husband was an alien at the time of the marriage, and became naturalized before September 22, 1922, the wife also acquired naturalized citizenship. If the marriage terminated, the wife maintained her U.S. citizenship if she was residing in the U.S. at that time and continued to reside in the U.S.
LIST "B"
(For Applicants for Uninsured Employers Fund or Subsequent Injuries Fund benefits who are citizens or nationals of the United States.)
* INS Form I-551 ("Resident Alien Card" or "Alien Registration Receipt Card", commonly known as a "green card") with one of the following INS class of admission ("COA") codes printed on the front of a white card or the back of a pink card: AR1, AR6, C20 through C29, CF1, CF2, CR1, CR2, CR6, CR7, CX1 through CX3, CX6 through CX8, F20 through F29, FX1 through FX3, FX6 through FX8, IF1, IF2, IR1 through IR4, IR6 through IR9, IW1, IW2, IW6, IW7, MR6, MR7, P21 through P23, or P26 through P28.
If an alien claiming approved status presents a code different than those enumerated, or if you cannot determine the class of admission from the I-551 stamp, you should file INS Form G-845, and the G-845 Supplement (mark item six on the Supplement) (attached hereto) along with a copy of the document(s) presented, with the local INS office in order to determine whether the applicant gained his or her status because he or she was the spouse, widow, or child of a U.S. citizen or the spouse, child, or unmarried son or daughter of an lawful permanent resident.
* INS Form I-551 with one of the following COA codes stamped on the lower left side of the back of a pink card: IB1 through IB3, IB6 through IB8, B11, B12, B16, B17, B20 through B29, B31 through B33, B36 through B38, BX1 through BX3, or BX6 through BX8.
* INS Form I-551 with COA code Z13.
* Unexpired Temporary I-551 stamp in foreign passport or on INS Form I-94 with one of the COA codes specified in the Subsections (1)-(3), above.
* INS Form I-797 indicating approval of an INS I-130 petition (only I-130 petitions describing the following relationships may be accepted: husbands or wives of U.S. citizens or LPRs, unmarried children under 21 years old of U.S. citizens or LPRs, or unmarried children 21 or older of LPRs), or approval of an I-360 petition (only I-360 approvals based on status as a widow/widower of a U.S. citizen or as a self-petitioning spouse or child of an abusive U.S. citizen or LPR may be accepted).
* A final order of an Immigration Judge or the Board of Immigration Appeals granting suspension of deportation under section 244(a)(3) of the INA as in effect prior to April 1, 1997, or cancellation of removal under section 240 A(b)(2) of the INA.
* INS Form I-797 indicating that the applicant has established a prima facie case; or
* An immigration court or Board of Immigration Appeals order indicating that the applicant has established a prima facie case for suspension of deportation under INA section 244(a)(3) as in effect prior to April 1, 1997, or cancellation of removal under section 240 A(b)(2) of the INA.
The benefit provider shall determine from the documentation when the petition was filed and take the actions set forth below:
* Applicants with petitions filed before June 7, 1997 should have an INS Form I-797 indicating filing of the I-360 petition by "self-petitioning spouse [or child] of abusive U.S.C. or LPR," a file-stamped copy of the petition, or another document demonstrating filing (including a cash register or computer-generated receipt indicating filing of Form I-360).
* Applicants with petitions filed after June 7, 1997 should have an INS Form I-797 indicating filing of the I-360 petition.
The following must indicate that the applicant is the widow/widower of a U.S. citizen, the husband or wife of a U.S. Citizen or LPR, the unmarried child under age 21 of a U.S. citizen or LPR, or the unmarried child age 21 or older of an LPR):
* For aliens on whose behalf a petition has been filed: INS Form I-797 indicating filing of an INS I-130 petition, a file-stamped copy of the petition, or another document demonstrating filing (including a cash register or computer-generated receipt indicating filing of Form I-130) (a sample copy of Form I-130 is attached to this Exhibit).
* For self-petitioning widows or widowers: a file-stamped copy of the INS I-360 petition, or another document demonstrating filing (including a cash register or computer-generated receipt indicating filing of Form I-360).
* an "Order to Show Cause";
* a "Notice to Appear"; or
* a "Notice of Hearing in Deportation Proceedings."
If the applicant has some documentation, but it is insufficient to demonstrate filing, establishment of prima facie case or approval of a petition, you should fax the INS Request Form on your agency letterhead, as well as a copy of any document(s) provided by the applicant, to the INS Vermont Service Center in order to determine the applicant's status. If the applicant has no documentation, but is certain that a petition has been filed by his or her spouse or parent, you should fax the INS Request Form to the INS Vermont Service Center.
Cal. Code Regs. Tit. 8, § 15741
Note: Authority cited: Sections 54, 55, 59, 3702.10, 3716, 3716.1, 3716.2 and 4751, Labor Code. Reference: Sections 1621, 1641 and 1642, Title 8, United States Code; and Sections 3716, 3716.1, 3716.2 and 4750- 4755, Labor Code.