Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (Farsi)

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State of California – Health and Human Services Agency
Department of Health Care Services
‫ﻣﺪﺍﺭﻙ ﻗﺎﺑﻞ ﻗﺒﻮﻝ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻳﺎ ﻫﻮﻳﺖ‬
Medi-Cal
‫ﻛﻪ ﺳﻴﺘﻲ ﺯﻥ ﻳﺎ ﺗﺎﺑﻊ ﺍﻳﺎﻻﺕ ﻣﺘﺤﺪﻩ ﻫﺴﺘﻨﺪ ﺑﺎﻳﺪ ﺳﻨﺪ‬
‫ﻳﻚ ﻗﺎﻧﻮﻥ ﺟﺪﻳﺪ ﻣﻲ ﮔﻮﻳﺪ ﻛﻪ ﺑﻴﺸﺘﺮ ﻣﺘﻘﺎﺿﻴﺎﻥ ﻭ ﺍﺳﺘﻔﺎﺩﻩ ﻛﻨﻨﺪﮔﺎﻥ‬
.‫ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻳﺎ ﻫﻮﻳﺖ ﺧﻮﺩ ﺭﺍ ﺍﺭﺍﺋﻪ ﺩﻫﻨﺪ‬
.‫ﻛﺎﻧﺘﻲ ﻣﺪﺭﻙ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻭ/ﻳﺎ ﻫﻮﻳﺖ ﺷﺨﺺ ﺯﻳﺮ ﺭﺍ ﻛﻪ ﺗﺴﻠﻴﻢ ﻛﺮﺩﻩ ﺍﻳﺪ ﺩﺭﻳﺎﻓﺖ ﻭ ﻣﺮﻭﺭ ﻛﺮﺩﻩ ﺍﺳﺖ‬
:‫ﻧﺎﻡ ﻣﺘﻘﺎﺿﻲ ﻳﺎ ﺍﺳﺘﻔﺎﺩﻩ ﻛﻨﻨﺪﻩ‬
‫ﻧﺎﻡ ﺧﺎﻧﻮﺍﺩﮔﻲ‬
‫ﻧﺎﻡ ﻣﻴﺎﻧﻲ‬
‫ﻧﺎﻡ‬
:‫ﺗﺎﺭﻳﺦ ﺗﻮﻟﺪ‬
:‫ﻧﺎﻡ ﺳﻨﺪ ﻫﻮﻳﺘﻲ ﻛﻪ ﺩﻳﺪﻩ ﺍﻳﺪ‬
:‫ﻧﺎﻡ ﺳﻨﺪ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻛﻪ ﺩﻳﺪﻩ ﺍﻳﺪ‬
‫ﺗﺼﻮﻳﺐ ﺷﺪﻩ. ﻣﺪﺭﻙ ﻫﻮﻳﺘﻲ ﻛﻪ ﺗﺴﻠﻴﻢ ﻛﺮﺩﻩ ﺍﻳﺪ ﺑﻌﻨﻮﺍﻥ ﻳﻚ‬
‫ﺗﺼﻮﻳﺐ ﺷﺪﻩ. ﻣﺪﺭﻙ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻛﻪ ﺗﺴﻠﻴﻢ ﻛﺮﺩﻩ ﺍﻳﺪ‬
‫ﺳﻨﺪ ﻫﻮﻳﺖ ﭘﺬﻳﺮﻓﺘﻪ ﻣﻲ ﺷﻮﺩ. ﻻﺯﻡ ﻧﻴﺴﺖ ﻛﻪ ﺑﺮﺍﻱ ﺷﺨﺺ‬
‫ﺑﻌﻨﻮﺍﻥ ﻳﻚ ﺳﻨﺪ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﭘﺬﻳﺮﻓﺘﻪ ﻣﻲ ﺷﻮﺩ. ﻻﺯﻡ ﻧﻴﺴﺖ‬
.‫ﺫﻛﺮ ﺷﺪﻩ ﺩﺭ ﺑﺎﻻ ﺩﻭﺑﺎﺭﻩ ﻣﺪﺭﻛﻲ ﺍﺭﺍﺋﻪ ﺩﻫﻴﺪ‬
.‫ﻛﻪ ﺑﺮﺍﻱ ﺷﺨﺺ ﺫﻛﺮ ﺷﺪﻩ ﺩﺭ ﺑﺎﻻ ﺩﻭﺑﺎﺭﻩ ﻣﺪﺭﻛﻲ ﺍﺭﺍﺋﻪ ﺩﻫﻴﺪ‬
‫ﺭﺩ ﺷﺪﻩ. ﺳﻨﺪﻱ ﻫﻮﻳﺘﻲ ﻛﻪ ﺗﺴﻠﻴﻢ ﻛﺮﺩﻩ ﺍﻳﺪ ﻗﺎﺑﻞ ﻗﺒﻮﻝ‬
‫ﺭﺩ ﺷﺪﻩ. ﺳﻨﺪﻱ ﻛﻪ ﺗﺴﻠﻴﻢ ﻛﺮﺩﻩ ﺍﻳﺪ ﻗﺎﺑﻞ ﻗﺒﻮﻝ ﻧﻴﺴﺖ. ﺷﻤﺎ‬
‫ﻧﻴﺴﺖ. ﺷﻤﺎ ﺑﺎﻳﺪ ﻳﻚ ﻣﺪﺭﻙ ﺩﻳﮕﺮ ﻫﻮﻳﺖ ﺗﺴﻠﻴﻢ ﻛﻨﻴﺪ. ﻳﻚ‬
‫ﺑﺎﻳﺪ ﻳﻚ ﻣﺪﺭﻙ ﺩﻳﮕﺮ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﺗﺴﻠﻴﻢ ﻛﻨﻴﺪ. ﻳﻚ ﻟﻴﺴﺖ‬
.‫ﻟﻴﺴﺖ ﺍﺳﻨﺎﺩ ﻫﻮﻳﺖ ﻗﺎﺑﻞ ﻗﺒﻮﻝ ﺑﻪ ﭘﻴﻮﺳﺖ ﺍﺭﺍﺋﻪ ﻣﻲ ﺷﻮﺩ‬
.‫ﺍﺳﻨﺎﺩ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻗﺎﺑﻞ ﻗﺒﻮﻝ ﺑﻪ ﭘﻴﻮﺳﺖ ﺍﺭﺍﺋﻪ ﻣﻲ ﺷﻮﺩ‬
‫ﻫﻤﻪ ﻣﺪﺍﺭﻙ ﺑﺎﻳﺪ ﺍﺻﻞ ﻣﺪﺭﻙ ﺑﻮﺩﻩ ﻳﺎ ﺭﻭﻧﻮﺷﺖ ﻫﺎﺋﻲ‬
‫ﻫﻤﻪ ﻣﺪﺍﺭﻙ ﺑﺎﻳﺪ ﺍﺻﻞ ﻣﺪﺭﻙ ﺑﻮﺩﻩ ﻳﺎ ﺭﻭﻧﻮﺷﺖ ﻫﺎﺋﻲ‬
‫ﺑﺎﺷﻨﺪ ﻛﻪ ﺑﻪ ﮔﻮﺍﻫﻲ ﺳﺎﺯﻣﺎﻥ ﺻﺎﺩﺭ ﻛﻨﻨﺪﻩ ﺭﺳﻴﺪﻩ‬
‫ﺑﺎﺷﻨﺪ ﻛﻪ ﺑﻪ ﮔﻮﺍﻫﻲ ﺳﺎﺯﻣﺎﻥ ﺻﺎﺩﺭ ﻛﻨﻨﺪﻩ ﺭﺳﻴﺪﻩ‬
.‫ﺍﺳﺖ. ﻓﺘﻮﻛﭙﻲ ﻗﺎﺑﻞ ﻗﺒﻮﻝ ﻧﻴﺴﺖ‬
.‫ﺍﺳﺖ. ﻓﺘﻮﻛﭙﻲ ﻗﺎﺑﻞ ﻗﺒﻮﻝ ﻧﻴﺴﺖ‬
‫ﺷﺨﺺ ﺫﻛﺮ ﺷﺪﻩ ﺩﺭ ﺑﺎﻻ ﺩﺭﺧﻮﺍﺳﺖ ﻫﺎﻱ ﺟﺪﻳﺪ ﻣﺮﺑﻮﻁ ﺑﻪ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻭ ﻫﻮﻳﺖ ﺭﺍ ﺍﳒﺎﻡ ﺩﺍﺩﻩ ﺍﺳﺖ ﺯﻳﺮﺍ ﻣﺪﺍﺭﻙ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻭ‬
.‫ﻫﻮﻳﺖ ﺍﻭ ﻫﺮ ﺩﻭ ﺑﻪ ﺗﺼﻮﻳﺐ ﺭﺳﻴﺪﻩ ﺍﻧﺪ‬
‫ﺷﺨﺺ ﺫﻛﺮ ﺷﺪﻩ ﺩﺭ ﺑﺎﻻ ﺩﺭﺧﻮﺍﺳﺖ ﻫﺎﻱ ﺟﺪﻳﺪ ﻣﺮﺑﻮﻁ ﺑﻪ ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻭ ﻫﻮﻳﺖ ﺭﺍ ﺍﳒﺎﻡ ﻧﺪﺍﺩﻩ ﺍﺳﺖ ﺯﻳﺮﺍ ﻳﻜﻲ ﻳﺎ ﻫﺮ ﺩﻭﻱ ﻣﺪﺍﺭﻙ‬
.‫ﺳﻴﺘﻲ ﺯﻥ ﺷﻴﭙﻲ ﻭ/ﻳﺎ ﻫﻮﻳﺖ ﻭﻱ ﺭﺩ ﺷﺪﻩ ﺍﺳﺖ ﻭ ﻳﺎ ﺍﺭﺍﺋﻪ ﻧﺸﺪﻩ ﺍﺳﺖ‬
.‫ﺍﮔﺮ ﻫﺮ ﮔﻮﻧﻪ ﺳﺆﺍﻟﻲ ﺩﺍﺭﻳﺪ ﻟﻄﻔﺄ ﺑﺎ ﺩﻓﺘﺮ ﺧﺪﻣﺎﺕ ﺍﺟﺘﻤﺎﻋﻲ ﻛﺎﻧﺘﻲ ﺧﻮﺩ ﺑﻪ ﺷﻤﺎﺭﻩ ﺗﻠﻔﻦ ﺫﻛﺮ ﺷﺪﻩ ﺩﺭ ﭘﺎﺋﲔ ﲤﺎﺱ ﺑﮕﻴﺮﻳﺪ‬
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 eligibility worker
Name of eligibility worker
(print):
First
Middle
Last
Telephone number:
County:
County fills out this box
Case No:
Case Name:
DHCS 0011 (06/08) – Farsi
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