Form 94 - Medicaid Application Form Page 3

ADVERTISEMENT

DECLARATION OF CITIZENSHIP/IMMIGRATION STATUS
I understand that the Ga. Division of Family and Children Services may require verification from the United States Department of Homeland Security
(D
of my/my children’s citizenship or immigration status when seeking benefits. Information received from DHS may affect my/my children’s eligibility.
Please fill out and sign ONE or BOTH of the following statements as it pertains to the status of each person seeking benefits.
CHILDREN SEEKING BENEFITS
U.S.
Lawfully
Date Naturalized
Citizen
Admitted
or Admitted into U.S.
Immigrant
Name
Place of Birth (city,state,country)
(
Check whichever applies)
(If applicable)
I, ________________________ attest to the identity of the child/children listed above and
(PRINT NAME)
certify under penalty of perjury, that the information written and checked above is true.
____________________________________
________________________
SIGNATURE (PARENT/GUARDIAN)
(DATE)
ADULT(S) SEEKING BENEFITS
U.S.
Lawfully
Date Naturalized
Citizen
Admitted
or Admitted into U.S.
Immigrant
Name
Place of Birth (city,state,country)
(If applicable)
(Check whichever applies)
I, _________________________________________ certify under penalty of perjury, that the information written and checked above is true.
(PRINT NAME)
____________________________________
________________________
SIGNATURE (PARENT/GUARDIAN)
(DATE)
______________________________________________________
_____________________________________
SIGNATURE (PARENT/GUARDIAN)
(DATE)
Form 94 (11/10)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form 216 - Medicaid Application Form 216 - Medicaid Application Medical
Medicaid Application Checklist Form Medicaid Application Checklist Form Medical
Form Wfnj-1jx - Cash Assistance/food Stamp/medicaid Application And Registration Form Wfnj-1jx - Cash Assistance/food Stamp/medicaid Application And Registration Legal
Electronic Funds Transfer (eft) Enrollment Form - Medicaid Application Center Electronic Funds Transfer (eft) Enrollment Form - Medicaid Application Center Business
Mad 023 - Medicaid Application For Women, Children, And Families Mad 023 - Medicaid Application For Women, Children, And Families Medical
Form Occ 94-36 - Fair Housing Lending Inquiry/application Log Sheet - Comptroller Of The Currency Form Occ 94-36 - Fair Housing Lending Inquiry/application Log Sheet - Comptroller Of The Currency Legal
Form Vs-94 - Public Emissions Inspection Waitlist Application Form Vs-94 - Public Emissions Inspection Waitlist Application Legal
Application For Retroactive Medicaid Coverage - Department Of Human Services - Case Records Management Unit Form Application For Retroactive Medicaid Coverage - Department Of Human Services - Case Records Management Unit Form Legal
Medicaid Ehr Incentive Program Health Information Exchange - Objective Stage 3 - Centers For Medicare And Medicaid Services Medicaid Ehr Incentive Program Health Information Exchange - Objective Stage 3 - Centers For Medicare And Medicaid Services Medical
Form St-r-42 - Application For Sale/use Tax Exemption Certificate For An Incorporated Nonprofit Statewide Organization That Advocate For Children And That Are Members Of The Medicaid Advisory Committee Form St-r-42 - Application For Sale/use Tax Exemption Certificate For An Incorporated Nonprofit Statewide Organization That Advocate For Children And That Are Members Of The Medicaid Advisory Committee Financial

Related Categories

Parent category: Medical
Download
Go
Page of 3