Form Dhcs 0005 - California Receipt Of Citizenship Or Identity Documents (Laotian) - Health And Human Services Agency

State of California – Health and Human Services Agency

Department of Health Care Services

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/ DSH/FQHC:

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BIC/CIN:

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gvdtlkomu j m j k owfh g sa o c,j o X\kp.lj | b j C 0= h ?

gvdtlkomu j m j k owfh g sa o c,j o X\kp.lj | b j C 0= h ?

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legoq k -b j C wfh I a [ dkoIa [ IvC3fpvq C dkomu j v vdgvdtlkooa h o

gvdtlkoou h c ,j o wfh I a [ X\kp.lj | b j C 0= h ?

gvdtlkoou h c ,j o wfh I a [ X\kp.lj | b j C 0= h ?

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X-n j c ]t7;k,lera o da [ z6 h I h v C0= s^ n z 6 h I a [ zq o xt3spf?

9q j C gia f legoq k 0vCgvdtlko1a h C 1n o la o -kf c]t}s^ n 8q ; [5 d 7q o mu j w fh I a [ 9kdz6 h I h v C0= s^ n z 6 h I a [ zq o xt3spfF c]tlq j C da [ 7n o gvdtlko8q h o lt[a [ .sh c dj z 6 h 4 n

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9tc9h C .sh z 6 h I h v C0= s^ n z 6 h I a [ zq o xt3spf0vC.[Ia [ ou h - k[;j k gvdtlkomu j 9 a f sk,k.sh o a h o c,j o pv,Ia [ wfh s ^ n [ + D mkCrtoa d Cko

DSH/FQHC

8h v Clq j C .[Ia [ lt[a [ ou h c]tlegoq k 0vCgvdtlko.sh c dj s h v Cdko[= ] y d kola C 7q , xt9e7k;8u h m u j g \ktlq , 8+ w xD

County/DSH/FQHC Staff reads and signs below.

I declare under penalty of perjury under the laws of the State of California that the information above is true

and correct.

Date:

Signature of County/DSH/FQHC Staff

Name of County/DSH/FQHC Staff

(print):

First

Middle

Last

Information:

Name of agency

County

Telephone number

E-mail

County fi lls out this box

Case No:

Case Name:

DHCS 0005 (02/08) – Laotian

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