Citizenship Verification Supplemental Form
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3Citizenship Supplemental Form
Under a new federal law U.S. citizens must prove their citizenship to get Medical Assistance. A separate proof of identity may also be
needed. On the back of this form is a list of the documents you can give us to prove citizenship and identity. Please look at this list to see
what documents you can give us. If you are on SSI, Social Security Disability, Foster Care, Adoption Assistance or Medicare or can only
get DC HealthCare Alliance benefits, you will not need to get the additional verification. Your caseworker will tell you if you need to get the
additional information.
Please list below everyone that you want to include in your application or recertification for Medical Assistance. Also, fill in the information
for each of those persons.
Name
Date of
Name of Father and Maiden
State, City,
Do you
Country of
Is this
(with Maiden name also)
Birth
Name of Mother
County of
have a B/C
Birth,
person a
birth, if born
for this
if born
U.S.
in the U.S.
person?
outside the
citizen?
U.S.
Yes or No
Yes or No
M)
1)
F)
M)
2)
F)
M)
3)
F)
M)
4)
F)
M)
5)
F)
M)
6)
F)
M)
7)
F)
Please sign below saying that the information you wrote on this form is true and that you know you may be breaking the law if you give
false information. Your signature also means that you looked at the list of documents on the back, and that you know that you need to give
us documents from this list to get or keep getting federal Medical Assistance. By signing this you also agree that you will tell us if you
cannot get these documents, or if you need more time to get them. Your signature also means you agree to tell us if you need our help in
getting these documents and gives us permission to request and receive birth certificates or other proof of citizenship for the persons in
your household.
__________________________________ _____________
___________________________________ ______________
Date
Date
Customer’s Signature
Worker’s Signature
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