Looking for a California Health And Human Services Agency Forms And Templates? Download it for free!

Form Dhcs 0005 - California Receipt Of Citizenship Or Identity Documents - Health And Human Services Agency

State of California – Health and Human Services Agency

Department of Health Care Services

Receipt of Citizenship or Identity Documents

Instructions to County/DSH/FQHC Staff

When you receive citizenship and/or identity document(s) for an

applicant or beneficiary, you must fill out this form.

Citizenship/Identity document for Applicant or Beneficiary:

______________________________________________________________Date of birth:_______________

First

Middle

Last

Address: ________________________________________________________________________________

Street

City

State

Zip Code

Name of parent if Applicant or Beneficiary is a child: ______________________________________________

First

Middle

Last

Applicant or Beneficiary BIC/CIN: ________________________________

Name of the citizenship/identity document you saw:

The document you saw was

(check one):

An original (not a photocopy or a notarized copy)

A copy that was certified by the issuing agency

This document was received

(check one):

By mail

In person (from the applicant or beneficiary)

Name:_____________________________

Name: _____________________________

In person (from a guardian, authorized

representative, or caretaker relative)

(Name and relationship to applicant or

beneficiary)

__________________________________

___________________________________

Make a photocopy of the citizenship and/or identity document received from the applicant or beneficiary, return

the original document(s) to the bearer and provide a copy of the signed receipt to the bearer. Once the

document is received by the eligibility worker, the county social services office will notify the applicant or

beneficiary of this receipt if the document(s) provided are acceptable. DSH/FQHC staff must send this receipt

and copies of the document(s) to the appropriate county social services office.

County/DSH/FQHC Staff reads and signs below.

I declare under penalty of perjury under the laws of the State of California that the information above is true

and correct.

__________________________________________________________

Date: ______________________

Signature of County/DSH/FQHC Staff

Name of County/DSH/FQHC Staff

(print):

First

Middle

Last

Information:

Name of agency

County

Telephone number

E-mail

County fills out this box

Case No:

Case Name:

DHCS 0005 (02/08)

Page 1 of 1

Form Dhcs 0005 - California Receipt Of Citizenship Or Identity Documents - Health And Human Services Agency

Related Articles

Related forms

Related Categories