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Form Dhcs 0003 - California Affidavit Of Reasonable Effort To Get Proof Of Citizenship - Health And Human Services Agency

State of California – Health and Human Services Agency

Department of Health Care Services

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County fills out this box

Case No:

Case Name:

If this Affidavit is taken on the phone, fill out below:

County worker’s name and signature

Date

DHCS 0003 (06/07) – Laotian

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Form Dhcs 0003 - California Affidavit Of Reasonable Effort To Get Proof Of Citizenship - Health And Human Services Agency

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