Form Mc 212 - Medi-Cal Residency Declaration (Declaracion De Medi-Cal Sobre Residencia)
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2State of California—Health and Human Services Agency
D epartment of Health Care Services
MEDI-CAL RESIDENCY
DECLARATION
(COUNTY STAMP)
Date: ________________________________
Case name: __________________________
Case number: _________________________
Worker name:
_________________________
District: ______________________________
EVERY APPLICANT FOR MEDI-CAL IS REQUIRED TO ANSWER THE FOLLOWING QUESTIONS ABOUT
RESIDENCY. PLEASE ANSWER “YES” OR “NO” TO QUESTIONS ONE THROUGH SIX AND SIGN AND DATE THE
FORM BELOW.
YES
NO
❒
❒
1. Do you or any family member own, lease, or maintain a home outside California?
❒
❒
2. Are you or any family member currently receiving public assistance from outside California?
❒
❒
3. Are you or any family member living outside California?
❒
❒
4. Are you or any family member in the United States on a Visa or a Border Crossing Card?
❒
❒
5. Are you or any family member planning to leave California for more than 60 days?
❒
❒
6. Do you and your family plan to stay permanently in California?
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE
ANSWERS I HAVE GIVEN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Applicant signature
Date
Signature of person acting for applicant
Date
MC 212 (05/07)
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