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

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State of California—Health and Human Services Agency
Department of Health Care Services
列出孩子的職務名稱，簡述孩子在工作期間的任務和遇到的問題。
第9部分——評論
第10部分——簽字和認證
本人在此聲明這份Supplemental Statement of Facts for Medi-Cal form和相關文件上的答案據我所知是真實無誤的，如有違反
願受State of California法律偽證罪處罰。
1. 兒童代理申請人簽名
與兒童關係
日期
地址（街道，門牌號）
城市
州
郵編
電話號碼
2. 證人簽名（如需要）
與兒童申請代理人的關係
日期
地址（街道，門牌號）
城市
州
郵編
電話號碼
MC 223C_CHI_0611
第9頁，共9頁

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