Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Armenian) Page 2
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9State of California—Health and Human Services Agency
Department of Health Care Services
County Use Only
Èð²òàôòÆâ îìÚ²Èܺð `ܲʲîºêì²Ì
County Number
Aid Code
Case Number
§MEDI-CAL¦-Æ ØƲÚÜ ºðºÊ²` ØÆÜâºì
18 î²ðºÎ²Ü, ¸ÆØàÔÆ Ð²Ø²ð
Ø²Ê 1` ²ÜÒÜ²Î²Ü îìÚ²Èܺð
A. ºñ»Ë³ÛÇ ³ÝáõÝÁ (³ÝáõÝÁ, ÙÇçÇÝ ³ÝáõÝÁ, ³½·³ÝáõÝÁ)
B. Social Security-Ç Ñ³Ù³ñÁ
C. ÌÝÝ¹Û³Ý ³Ùë³ÃÇíÁ
F. ø³ßÁ ýáõÝï»ñáí
D. ê»éÁ
E. гë³ÏÁ
ýáõï__________ ¹ÛáõÛÙ__________
³ñ³Ï³Ý
Ç·³Ï³Ý
G. àõ±Ù Ñ»ï ¿ ³åñáõÙ »ñ»Ë³Ý
²ÝáõÝÁ
²éÝãáõÃÛáõÝÁ
лé³ËáëÇ Ñ³Ù³ñÁ
лé³Ëáë ãϳ
´Ý³ÏáõÃÛ³Ý Ñ³ëó»Ý (ѳٳñÁ, ÷áÕáóÁ)
ø³Õ³ùÁ
ܳѳݷÁ
öáëï³ÛÇÝ Çݹ»ùëÁ
H. öáëï³ÛÇÝ Ñ³ëó»Ý (»Ã» ï³ñµ»ñ ¿ µÝ³ÏáõÃÛ³Ý Ñ³ëó»Çó)
ܳѳݷÁ
öáëï³ÛÇÝ Çݹ»ùëÁ
гëó»Ý (ѳٳñÁ, ÷áÕáóÁ)
ø³Õ³ùÁ
I. ºñ»Ë³ÛÇ Ñ³Ù³ñ ¹ÇÙáÕ ³ÝÓÁ
²ÝáõÝÁ
²éÝãáõÃÛáõÝÁ
лé³ËáëÇ Ñ³Ù³ñÁ
лé³Ëáë ãϳ
àõÕ»ñÓÝ»ñ ÃáÕÝ»Éáõ Ñ»é³ËáëÇ Ñ³Ù³ñÁ
²ÛÝ ³ÝÓÇ ³ÝáõÝÁ, áõÙ å»ïù ¿ áõÕ»ñÓÁ ÃáÕÝ»É
J. à±ñ É»½íáí/µ³ñµ³éáí ¿ »ñ»Ë³ÛÇ Ñ³Ù³ñ ¹ÇÙáÕ ³ÝÓÁ ËáëáõÙ ¨ ϳñ¹áõÙ ³Ù»Ý³É³íÁ:
Ø²Ê 2ª ºÐºÊ²ÚÆ ÐÆ̲ܸÀÔÂÚÀÔÜܺÐÀ« ÌܲÊ̲ÌØܺÐÀ Î²Ø ²ÈÀÔÆ²Î²Ü ÊܸÆÐܺÐÀ
County Use Only
º±ñµ ¿ ³ÛÝ ëÏëí»É
A. ƱÝã ÑÇí³Ý¹áõÃÛáõÝÝ»ñ, íݳëí³ÍùÝ»ñ ϳ٠³éáÕç³Ï³Ý ËݹÇñÝ»ñ áõÝÇ »ñ»Ë³Ý
(³ÙÇëÁ/ï³ñÇÝ)
MC 223C_ARM_0611
¾ç 2` 9 ¿çÇó
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