Affidavit Restrictions On Public Benefits {DR 4679)

DR 4679 (03/24/14) COLORADO DEPARTMENT OF REVENUE Affidavit - Restrictions On Public Benefits I, ______________________________________________________________ , swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one): I am a United States citizen. I am not a United States citizen but I am a Permanent Resident of the United States. I am not a United States citizen but I am lawfully present in the United States pursuant to Federal law. I am a foreign national not physically present in the United States. I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received. Signature Date (MM/DD/YY) American LegalNet, Inc. www.FormsWorkFlow.com