Form MC13: Citizenship/Immigration Status Information

Under Individual Information, enter the Print name (First, Middle, Last) and the Date.

Under SECTION A: CITIZENSHIP INFORMATION, select YES or NO for 1. Are you a citizen or a national of the United States?

If yes, enter where you were born (City/State).

If you are a naturalized citizen or a national of the United States, provide your Country of Birth and one of the following: Passport Number, Naturalization Number, or other.

Proceed to SECTION C if you answered YES to question 1.

Under SECTION B: NON-CITIZEN IMMIGRATION STATUS INFORMATION, write your current immigration status (e.g., Lawful Permanent Resident (LPR), Refugee, Asylee, etc.) on line 1 below if known.

Enter the Name as it appears on your immigration document, Date of birth, Country of birth, and Date you entered the U.S. (Month/Date/Year).

If you have an immigration document (Legal Permanent Resident Card (I-551), Employment Authorization Document (I-766), I-94, Visa, or other), provide the document type and number (for example, A-Number, I-94 Number, Visa Number, SEVIS ID, or USCIS Receipt Number).

Select YES or NO for 3. Do you have a Permanently Residing Under the Color of Law (PRUCOL) status?

If YES, check the box to indicate your specific PRUCOL status in the PRUCOL status list:

 A conditional entrant admitted to the United States before April 1, 1980.

 An individual paroled into the United States, including Cuban/Haitian entrants.

 An individual under an active Order of Supervision.

 An individual granted an indefinite stay of deportation.

 An individual granted an indefinite voluntary departure.

 An individual on whose behalf an immediate relative petition (Form I-130) has been approved and who is permitted voluntary departure.

 An individual who has properly filed an application for lawful permanent resident status.

 An individual granted a time-limited stay of removal.

 An individual granted asylum.

 An individual admitted to the United States as a refugee on or after April 1, 1980.

 An individual granted voluntary departure who is awaiting issuance of a visa.

 An individual with deferred action status.

 An individual who entered and has continuously resided in the United States since before January 1, 1972, and who is eligible to adjust to lawful permanent resident status under INA section 249 (Registry).

 An individual granted a suspension of removal and whose departure USCIS does not intend to enforce.

 An individual granted withholding of removal pursuant to INA Section 243(h).

An individual, not included in the other PRUCOL categories in the PRUCOL status list, whose presence is known to USCIS and for whom USCIS does not plan to pursue removal, either due to the individual's status category or specific circumstances.

Under SECTION C: DECLARATION AND SIGNATURE, you declare under penalty of perjury under the laws of the State of California that the answers you have given are correct and true to the best of your knowledge.

Sign the Individual/Applicant signature line and enter the Date.

Enter the Print name of person acting for individual and the Relationship to individual, sign the Signature of person acting for the individual line and enter the Date.