Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Korean) Page 9

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State of California—Health and Human Services Agency
Department of Health Care Services
이 어린이의 직책 명, 간단한 업무내용 및 그 일을 하면서 그 어린이가 겪었을 수도 있는 어떠한 문제라도 기록하십시오.
파트 9 — 참조
파트 10 — 서명 및 인증
나는 State of California 의 법률에 따라 위증의 처벌을 받을 것을 감수하고 내가 본 Supplemental Statement of Facts for
Medi-Cal form 및 다른 서류들에서 답변한 내용들은 나의 지식과 믿음에 따라 최대한 정확하고 진실된 것임을 선서합니다.
1. 이 어린이를 위해 신청하는 사람의 서명
이 어린이와의 관계
일자
주소 (지번, 거리)
시
주
우편번호
전화번호
2. 증인의 서명 (해당되는 경우)
신청하는 이 어린이와의 관계
일자
주소 (지번, 거리)
시
주
우편번호
전화번호
페이지 9 / 9
MC 223C_KOR_0611

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