Form Dhcs 0003 - California Affidavit Of Reasonable Effort To Get Proof Of Citizenship - Health And Human Services Agency

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State of California – Health and Human Services Agency
Department of Health Care Services
Affidavit of Reasonable Effort to Get Proof of Citizenship
Fill out below
(print)
I am trying to get proof of citizenship for
(name):
First
Middle
Last
I have tried to get proof of citizenship from the people or agencies listed below.
(Also list dates of contact and how long it will take to get the proof of citizenship.)
Name of person or
Document
Date
Date they will
agency contacted
requested
contacted
respond
Explain below any other information about your efforts to get proof of citizenship:
Your name (print)
Your signature
Date
If you need help with this form, please call your local social services office.
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)
Page 1 of 1

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