Loading...
HomeMy WebLinkAboutRESPONSE - RFP - P1037 SOUTHRIDGE RESTAURANT/SNACK BAR CONCESSIONAIRE (23)EXHIBIT G AFFIDAVIT PURSUANT TO C.R.S. 24-76.5-103 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, or ___ I am a Permanent Resident of the United States, or ___ I am lawfully present in the United States pursuant to Federal law. 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 INTERNAL USE ONLY Valid forms of identification ---current Colorado driver’s license, minor driver’s license, probationary driver’s license, commercial driver’s license, restricted driver’s license, instruction permit ---current Colorado identification card ---U.S. military card or dependent identification card ---U.S. coast guard merchant mariner card ---Native American tribal document The following forms of identification may be accepted through February 28, 2007* ---original birth certificate from any state of the United States ---certificate verifying naturalized status by U.S. with photo and raised seal ---certificate verifying U.S. citizenship by U.S. government, e.g., U.S. passport ---order of adoption by a U.S. court with seal of certification ---valid driver’s license from any state of the U.S. or the Dist. of Columbia excluding AK, HI, IL, MD, MI, NE, NM, NC, OR, TN, TX, UT, VT and WI ---valid immigration documents demonstrating lawful presence, e.g., current foreign passport with current I-551 stamp or visa, current foreign passport with I-94, I-94 with asylum status, unexpired Resident Alien card, Permanent Resident card or Employment Authorization card *A waiver may be available where no identification exists or can be obtained due to a medical condition, homelessness, or insufficient documentation to receive a Colorado I.D. or driver’s license. Contact your department director.