Declaration of Citizenship Status Form

Notice to applicants and tenants: In order to be eligible to receive the housing assistance sought, each applicant for, or recipient of , housing assistance must be lawfully within the U.S. Please read the Declaration statement carefully and sign.
Date of Declaration*
MM slash DD slash YYYY
Name of Person Declaring or Family Representative Signature*
First Middle Last
(If person declaring is child under age 17. )
Name of Household Member*
First Middle Last
Email*
Citizenship Status*
- Citizen
- National
- Non Citizen
- Non Citizen Student
- Citizen - A citizen or national of the United States.
- National - A person who owes permanent allegiance to the United States; for example , as a result of birth in a United Stats territory or possession.
- Non Citizen - A person who is neither a citizen nor a national of the United States.
- Non Citizen Student - A person who has a residence in a foreign country and has no intention of abandoning, is a bonafide student qualified to pursue a full course of study, and is admitted to the U.S. temporarily and solely for purposes of pursuing such a course of study at a recognized place of study and specifically designated and approved by the AG.
Certification Agreement*
UNDER PENALTY OF PERJURY, I certify the information noted above is accurate and up to date, AND I AM LAWFULLY WITHIN THE UNITED STATES. I certify the name above is that of an approved family representative.
- I agree to the Certification Agreement

Contact Information

Community Development & Housing Department
216 N. Broadway St., Suite G.
Pittsburg, KS 66762
(620) 232-1210

Hours of Operation:

Monday - Friday
8:00 am - 5:00 pm