Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (Hmong) - Health And Human Services Agency
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1State of California – Health and Human Services Agency
Department of Health Care Services
Cov Puavpheej Uas Qhia Tias Yog Neeg Amelikas thiab
Qhia Tias Koj Yog Leejtwg Tiag Uas Luag Kam Txais
Ib tsab kevcai tshiab hais tias yuav luag txhua tus neeg uas tau txais thiab tabtom tuaj thov Medi-Cal uas yog neeg
Amelikas (U.S. citizens) lossis neeg ntawm lub tebchaws no yuavtsum tau muaj tej puavpheej uas qhia tias nws yog
neeg Amelikas thiab yog leejtwg tiag.
Lub county tau txais thiab tshuaj cov puavpheej uas qhia tias yog neeg Amelikas thiab/lossis yog leejtwg tiag uas koj
tau xa tuaj txog:
Tus neeg tabtom Tuaj Thov
lossis tus neeg Tau Txais lub Npe:
:
Hnub yug
Lub npe ntawm daim puavpheej uas qhia tias yog
Lub npe ntawm daim puavpheej uas qhia tias yog
neeg Amelikas uas koj pom:
leejtwg tiag uas koj pom:
Kam txais. Peb kam txais daim puavpheej uas qhia
Kam txais. Peb kam txais daim puavpheej uas qhia
tias yog neeg Amelikas uas koj tau xa tuaj. Koj yuav
tias yog leejtwg tiag uas koj tau xa tuaj. Koj yuav tsis
tsis tau xa tej puavpheej no ntxiv txog tus neeg uas
tau xa tej puavpheej no ntxiv txog tus neeg uas hais
hais saumtoj no lawm.
saumtoj no lawm.
Tsis kam txais. Peb tsis kam txais daim puavpheej
Tsis kam txais. Peb tsis kam txais daim puavpheej
uas koj xa tuaj. Koj yuavtsum tau xa lwm yam
uas qhia tias yog leejtwg tiag uas koj xa tuaj. Koj
puavpheej uas qhia tias yog neeg Amelikas tuaj.
yuavtsum tau xa lwm yam puavpheej uas qhia tias yog
Hauv qab no yog cov ntaub ntawv uas peb kam txais
leejtwg tiag tuaj. Hauv qab no yog cov ntaub ntawv uas
ua puavpheej qhia tias yog neeg Amelikas.
peb kam txais ua puavpheej qhia tias yog leejtwg tiag.
• Txhua daim ntaub ntawv yuavtsum yog daim
• Txhua daim ntaub ntawv yuavtsum yog daim
tseem lossis muaj lub koomhaum uas ua daim
tseem lossis muaj lub koomhaum uas ua daim
ntawv ntawd lub cim nias rau tias yog daim tseem.
ntawv ntawd lub cim nias rau tias yog daim tseem.
Peb yuav tsis kam txais tej uas koj luam tuaj.
Peb yuav tsis kam txais tej uas koj luam tuaj.
Tus neeg saumtoj no tau muaj tej yam uas qhia tau tias nws yog neeg Amelikas thiab yog leejtwg tiag lawm vim
peb kam txais cov puavpheej uas qhia tias nws yog neeg Amelikas thiab yog leejtwg tiag lawm.
Tus neeg saumtoj no tseem tsis tau muaj tej yam uas qhia tau tias nws yog neeg Amelikas thiab yog leejtwg tiag
vim peb tsis kam txais ib lossis ob yam puavpheej uas qhia tias nws yog neeg Amelikas thiab/lossis yog leejtwg tiag
lossis nws tsis tau xa tuaj rau peb.
Yog tias koj muaj lus nug dabtsi, thov hu mus rau lub chaw pabcuam pejxeem hauv koj lub county ntawm tus
xovtooj uas teev rau hauv qab no.
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 fi lls out this box
Case No:
Case Name:
DHCS 0011 (06/08) – Hmong
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