Form Dhcs 0010 - California Affidavit Of Identity For U.s. Citizen Or National For Disabled Individuals Living In Institutional Care Facilities - Health And Human Services Agency

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State of California – Health and Human Services Agency
Department of Health Care Services
Affidavit of Identity for U.S. Citizen or National For
Disabled Individuals Living in Institutional Care Facilities
To the institutional/residential facility director or
administrator:
•
Fill out and sign below.
•
Print neatly and submit to the county social services office.
Important!
All other means of verifying identity must be pursued
before submitting this affidavit to the county.
Identity of Disabled Individual
Name of individual
First
Middle
Last
Institutional/residential care director or administrator reads and signs below.
On behalf of the above individual, under penalty of perjury under California state law, I declare the identity of
the person named above.
_______________________________________________________
Date:____________________
S
ignature of institutional/residential facility director or administrator
________________________________________________________
Name of institutional/residential facility director or administrator (print)
________________________________________________________
Name of institutional/residential facility
Address ________________________________________________________________________________
City
State
Zip
____________________________________
______________________________________
e
l
Telephone
-mai
If you have questions, please contact the county social services office at:
County fills out this box
Case No:
Case Name:
DHCS 0010 (01/08)
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