Citizenship Verification Supplemental Form Page 2
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3Documents Proving Identity and Citizenship
A federal law adds two new requirements for Medicaid. We need to see documents that show who you are
(identification), and that you are a US citizen. We must see the originals or certified copies of any papers you want
us to see. We cannot accept photocopies. Also, we need to see these documents within 90 days or you may not be
eligible for Medicaid. If you have problems getting any of these documents, tell us about the problems you are
having. We may be able to help you get some documents.
This rule is to prove identity and citizenship is for everyone you are applying for. You can do this in several ways:
A) Show us any of these documents and you don’t need any others. They are official records that show both who
you are and that you are a US citizen:
US passport, even if it is not current
Certificate of Naturalization (N-550 or N-570) given to people from other countries who become US
citizens
Certificate of Citizenship (N-560 or N-561) given to children who become US citizens through their
parent(s)
If you don’t have any of these documents, you can still comply by showing two documents. One document says who
you are. The other one must show that you are a US citizen.
B) To show who you are, show us one of the following:
Official driver’s license with your photograph or with identifying information like name, age, sex,
height, weight, or eye color.
School identification card with a photograph
US military card or draft record
ID card issued by Federal, State, or Local government showing the same information as a driver’s
license
Military dependent’s identification card
Native American Tribal Document
Certificate of Degree of Indian Blood, or other US American Indian/Alaska Native tribal document,
showing the same information as a driver’s license
US Coast Guard Merchant Mariner card
if none of these is available, you may present at least three of the following:
o High school diploma, college diploma, marriage certificate, divorce decree, property
deed/title, employer id
for children under 16,
o Nursery or daycare record showing date and place of birth
o School record that shows date and place of birth and parent(s) name
o Clinic, doctor or hospital record showing date of birth
o If none of these is available, a parent or guardian or caretaker relative can sign an
affidavit. It must state the date and place of the birth of the child. This cannot be used if
an affidavit is also being used to show the child is a US citizen.
C) To show you are a US citizen, show us one of the following. We need to see whichever document you can get
that is highest on this list:
1. If you were born in the US, a US public birth certificate or record issued by the State, Commonwealth,
territory or local jurisdiction, recorded before you were 5 years old
2. If you were born outside the US but were a US citizen at birth, you may show us a Certification of Report
of Birth (DS-1350), Consular Report of Birth Abroad of a Citizen of the United States of America (FS-240),
or Certification of Birth Abroad (FS-545). These are issued by the Department of State to Americans who
were born abroad
3. If you are a naturalized US Citizens living near the border, you may show a US Citizen Identification Care
(I-97 or I-179), issued by the Immigration and Naturalization Service
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