Form Dhcs 0003 - California Sinumpaang Pahayag Ng Katamtamang Pagsisikap Upang Makakuha Ng Katunayan Ng Pagiging Mamamayan - Health And Human Services Agency
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1State of California – Health and Human Services Agency
Department of Health Care Services
Sinumpaang Pahayag ng Katamtamang Pagsisikap Upang Makakuha ng
Katunayan ng Pagiging Mamamayan
Sagutan ang nasa ibaba
(ilimbag)
Sinusubukan kong makakuha ng katunayan ng pagiging mamamayan
(pangalan):
Pangalan
Gitna
Apelyido
Sinubukan kong kumuha ng katunayan ng pagiging mamamayan mula sa mga tao o ahensiyang nakalista sa
ibaba.
(Ilista din ninyo ang mga petsa ng pagkontak at kung gaano katagal aabutin ang pagkuha ng katunayan ng
pagiging mamamayan.)
Pangalan ng tao o
Dokumentong
Petsa ng
Petsa kung kailan
ahensiyang kinontak
hiniling
pag-kontak
sila sasagot
Ipaliwanag sa ibaba ang anumang mga ibang impormasyon tungkol sa inyong pagsisikap upang makakuha ng
katunayan ng pagiging mamamayan:
Ang inyong pangalan (ilimbag)
Ang inyong pirma
Petsa
Kung kailangan ninyo ng tulong sa pormas na ito, mangyaring kontakin ang inyong lokal na opisina para sa
mga serbisyong panlipunan.
Sasagutan ng county ang kahon sa ibaba
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) – Tagalog
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