Verification of Lawful Presence 
 City Clerk (303) 658-2162 
 4800 West 92nd Avenue FAX (303) 706-3924 
 Westminster, CO 80031 www.CityofWestminster.us 
 CITY USE ONLY 
 Legal/True Name of Business (from line 1 of Business Registration)  Acct 
 
Colorado state law requires individuals and sole proprietors applying for local public benefits complete both parts below. 
 Submit this form along with a completed and signed Business Registration form. 
   
I,    , swear or affirm under penalty of perjury under the laws
of the State of Colorado that (check only one): 
  
  I am a United States Citizen. 
  I am a Permanent Resident of the United States. 
  I am lawfully 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 the receipt of this public 
PART A - Affidavit 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 the State 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 
Colorado law also requires the applicant for a public benefit to produce for the City of Westminster  one of the 
authorized documents listed below in order to verify lawful presence in the United States. The applicant may either (a) 
produce such document in person (along with the completed, signed Business Registration form) at the office of the 
City Clerk; or submit this form fully executed and notarized below along with a clear, legible copy of such document. 
   
Check the box which represents the authorized identification you will submit (check only one). 
  A valid Colorado driver’s license or Colorado identification card issued pursuant to Article 2 of Title 42, C.R.S. 
  A valid United States military identification card or military dependent’s identification card. 
  A valid United States Coast Guard Merchant Mariner card. 
  A valid Native American tribal document. 
  
  Submitted in person to ___________________ at the City of Westminster.  Notarized below and returned. 
  
If you are  submitting a  clear, legible  copy of the  above authorized identification, you  must have a notary public 
complete the following section: 
 
STATE OF COLORADO ) 
)ss.
COUNTY OF _______________  ) 
  
 The foregoing instrument was acknowledged before me 
 this _____ day of ______________________, 20_____. 
PART B – Verification of Authorized Identification 
  S E A L 
 Witness my hand and official seal. 
    
Notary Public
  
Commission Expires