07/15/15 DFPC FORM-3007
Colorado Department of Public Safety
Division of Fire Prevention and Control
700 Kipling Street, Suite 4100
Lakewood, CO 80215
(303)239-4100 phone (303)239-4131 fax
cdps_dfpc_suppression@state.co.us or
cdps_dfpc_fireworks@state.co.us http://dfs.state.co.us
I, _____________________________________________________, swear or affirm under penalty of
perjury under the laws of the State of Colorado that (please 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.
Verification of Legal Residency
I HAVE ATTACHED A PHOTOCOPY of identification of legal residency to establish lawful presence in the
United States. The following forms of identification are acceptable pursuant to the Colorado Department of Revenue*:
• A valid State driver’s license or a State identification card,
issued pursuant to Article 2 of title 42, C.R.S.; or
• A United States military card or military dependent’s identification
card; or
• A United States Coast Guard Merchant Mariner card; or
• A Native American tribal document
Subscribed and affirmed, or sworn before me in the
County of:
My commission expires:
Notary Public Signature:
*Please visit the Colorado Department of Revenue web site for additional information and alternative acceptable identification documents: Colorado Department of Revenue
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