Form Dhcs 0003 - California Declaracion Jurada De Esfuerzo Razonable Para Obtener Prueba De Ciudadania - Health And Human Services Agency

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State of California – Health and Human Services Agency
Department of Health Care Services
Declaración jurada de esfuerzo razonable para obtener prueba de ciudadanía
Llene abajo
(en letra de molde)
Estoy tratando de obtener prueba de ciudadanía de
(nombre):
Primer nombre
Segundo nombre
Apellido
Traté de obtener prueba de ciudadanía de las personas o entidades indicadas abajo.
(Escriba también las fechas de contacto y cuánto tomará obtener la prueba de ciudadanía).
Nombre de la persona o de la agencia
Documento
Fecha en que se
Fecha en que
con que se puso en contacto
solicitado
puso en contacto
responderán
Escriba abajo la demás información, si la hay, sobre sus esfuerzos para obtener prueba de ciudadanía:
Su nombre
(en letra de molde)
Su firma
Fecha
Si necesita ayuda con este formulario, llame a la oficina local de servicios sociales.
El condado llenará la casilla a continuación
County fills out this box
Case No:
Case Name:
If this Affidavit is taken on the phone, fill out below:
County worker’s name and signature
Date
DHCS 0003 (06/07) - Spanish
Page 1 of 1

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