Citizenship Verification Supplemental Form (Page 3 of 3) in pdf

4. If you are a member of the Texas Band of Kickapoos, you may show an American Indian Card (I-872

showing a classification code of “KC”)

5. If you were born in the Northern Mariana Islands, you may show a Northern Mariana Card (I-873)

6. If you were adopted, you may show a final adoption decree, showing the child’s name and US place of

birth. If an adoption is not finalized, talk to us about other adoption documents

7. Evidence of US government civil service employment before June 1, 1976

8. Official Military record of service showing a US place of birth (like a DD-214)

9. Extract of a hospital record on hospital letterhead established at the time of birth. It must be dated at least

five years before you apply for Medicaid. Souvenir “birth certificate” issued by the hospital cannot be used

10. Life, health, or other insurance records at least 5 years old showing a US place of birth

11. Religious record of birth in the US within 3 months of birth showing a US place of birth and parent’s place

of birth and age or date of birth

12. Early school record showing date of birth, a US place of birth, and the names and places of birth of your

parent(s)

13. If you were born between 1900 and 1950, you may show us a Federal or State census record. It must

show US citizenship or a US place of birth and your age at the time of the census. You can get this

record from the US Census Bureau. It costs $65 for them to search for this for you

14. Seneca Indian tribal census record at least 5 years before the application for Medicaid

15. Navaho Indian tribal census record from the Bureau of Indian Affairs at least 5 years before the

application for Medicaid

16. US State Vital Statistics official notification of birth registration at least 5 years before the application for

Medicaid

17. Amended US public birth record that was amended more than 5 years after birth. It must be dated at

least 5 years before the application for Medicaid

18. Statement signed by the physician or midwife who was in attendance at the time of birth. It must show the

date and place of birth. It must also be dated at least 5 years before the application for Medicaid

19. The Roll of Alaska Natives maintained by the Bureau of Indian Affairs

20. Nursing facility or other institution admission papers showing a US place of birth. It must be dated at

least 5 years before the application for Medicaid

21. For someone 16 years or older, medical records from clinics, doctors, or hospitals. The record must be

dated at least 5 years before the application for Medicaid. Immunization records cannot be used

22. For someone under the age of 16, medical records from clinics, doctors, or hospitals. The record must

show a US place of birth. The record must be dated near the time of birth or at least 5 years before the

application for Medicaid. Immunization records cannot be used

23. If you cannot provide any of these documents, you can provide 2 written affidavits. These statements

must be signed under the penalty of perjury. They must be signed by persons who personally know when

and where you were born or how you became a US citizen, and they must state how they know this. At

least one of the affidavits must be from someone not related to you. The persons signing the affidavits

must be able to prove their own citizenship and identity. You must also provide an affidavit explaining

why none of the documents listed above are available.

Citizenship Verification Supplemental Form Page 3