This document is a declaration for a visa applicant to Israel. It outlines the 4 types of visas the applicant may be eligible for: 1) immigration visa, 2) student visa, 3) tourist visa, or 4) temporary resident visa. It notes that those receiving a temporary resident visa are entitled to immigration assistance only once and cannot later change their status and receive assistance again. The applicant must declare whether they have previously resided in Israel on an immigration or temporary resident visa and provide those details. They must also provide same for any spouse. The document is signed and dated by the applicant and witnessed.

1. DECLARATI0N
I, _________________ the undersigned, declare that I have been made fully, aware that I am
entitled to be in Israel on any of the following visas: (mark one)
1. On an Immigration (Oleh) visa, by the Law of Return, if I intend to settle permanently in
Israel.
2. Or on a student visa (A-2), if I intend to come to Israel for the purpose of study only.
3. Or on a tourist visa (B-2), if at the present time I do not plan to settle in Israel.
4. Or on a temporary resident visa (A-1), if I intend to explore the possibilities of settling in
Israel within a period of 3 years.
Furthermore, I have been made aware that upon receipt of the A-1 visa I am entitle to the
assistance given by the state of Israel to immigrants, and that I am entitled to this assistance
one time only, and cannot request it a second time upon changing my status from
Temporary Resident (A-1) to Immigrant (Oleh).
I declare that:
1. I have never in the past resided in Israel as an immigrant or as a temporary resident (A-1).
2. I have resided in Israel from__________________ on a _____________ visa.
Year
My identity number was / is ______________________.
3. My husband/wife resided in Israel from_____________on a _________visa.
Year
His / her identity number was / is ___________________.
____________________ ______________________
Signature Date
I hereby confirm that this declaration was signed before me after its contents were read and further
reviewed and clarified by me.
_______________________ ______________________
Shaliach/Representative Signature Date