Form Dhcs 0004 - California Request For California Birth Record (Arabic) - Health And Human Services Agency

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State of California – Health and Human Services Agency
Department of Health Care Services
‫ﻃﻠﺐ اﳊﺼﻮل ﻋﻠﻰ ﺳﺠﻞ وﻻدة ﻣﻦ ﻛﺎﻟﻴﻔﻮرﻧﻴﺎ‬
!ً ‫ ﻃﻠﺐ اﳊﺼﻮل ﻋﻠﻰ ﺳﺠﻞ وﻻدة ﻷﺷﺨﺎص ﻣﻮﻟﻮدﻳﻦ ﻓﻲ ﻛﺎﻟﻴﻔﻮرﻧﻴﺎ — ﻣﺠﺎﻧ ﺎ‬Medi-Cal ‫ﺗﺴﺘﻄﻴﻊ‬
: ‫ﺗﺎرﻳﺦ اﻟﻴﻮم‬
:‫اﻟﺴﻨﺔ‬
:‫اﻟﻴﻮم‬
:‫اﻟﺸﻬﺮ‬
:‫إﺗﺒﻊ اﻟﺘﺎﻟﻲ‬
:‫اﺳﻢ اﻟﺸﺨﺺ اﳌﺘﻘﺪم ﺑﺎﻟﻄﻠﺐ‬
:‫اﻷﺧﻴﺮ‬
:‫اﻟﻮﺳﻂ‬
:‫اﻷول‬
‫اﻣﻸ ﻫﺬا اﻟﻄﻠﺐ. اﻃﺒﻊ او‬
•
‫اﻛﺘﺐ ﺑﺄﺣﺮف ﻛﺒﻴﺮة ﺑﺨﻂ‬
‫ﻣﺮﺗﺐ. ﺑﺎﻣﻜﺎﻧﻚ اﺳﺘﺨﺪام‬
‫ﻣﻦ اﻟﺬي ﺗﺮﻳﺪ اﳊﺼﻮل ﻟﻪ ﻋﻠﻰ ﺳﺠﻞ وﻻدة؟‬
‫اﳌﻌﻠﻮﻣﺎت اﳌﻮﺟﻮدة ﻓﻲ‬
:‫اﻷﺳﻢ ﻓﻲ ﺷﻬﺎدة اﳌﻴﻼد‬
:‫اﻷﺧﻴﺮ‬
:‫اﻟﻮﺳﻂ‬
:‫اﻷول‬
‫ﻧﺴﺨﺔ ﻣﻦ ﺷﻬﺎدة اﳌﻴﻼد ﳌﻸ‬
،‫اذا ﻛﺎن ﻗﺪ ﰎ ﺗﺒﻨﻲ ﻫﺬا اﻟﺸﺨﺺ‬
.‫ﻫﺬا اﻟﻄﻠﺐ‬
:‫اﻛﺘﺐ اﺳﻢ اﻟﺘﺒﻨﻲ‬
:‫اﻷﺧﻴﺮ‬
:‫اﻟﻮﺳﻂ‬
:‫اﻷول‬
‫• ﺧﺬ أو أرﺳﻞ اﻟﻄﻠﺐ اﳌﻌﺒﺄ‬
o
o
:‫اﳉﻨﺲ‬
‫اﻟﻰ ﻣﻜﺘﺐ اﳋﺪﻣﺎت‬
‫اﻧﺜﻰ‬
‫ذﻛﺮ‬
.‫اﻷﺟﺘﻤﺎﻋﻴﺔ اﶈﻠﻲ‬
:‫ﺗﺎرﻳﺦ اﳌﻴﻼد‬
:‫اﻟﺴﻨﺔ‬
:‫اﻟﻴﻮم‬
:‫اﻟﺸﻬﺮ‬
‫• اذا ﻛﻨﺖ ﺗﻮاﺟﻪ ﻣﺸﻜﻠﺔ‬
:‫اﳌﻘﺎﻃﻌﺔ وﻣﺪﻳﻨﺔ اﳌﻴﻼد‬
:‫ﻣﻘﺎﻃﻌﺔ ﻛﺎﻟﻴﻔﻮرﻧﻴﺎ‬
:‫اﳌﺪﻳﻨﺔ‬
‫ﻓﻲ ﻣﻠﺊ ﻫﺬا اﻟﻄﻠﺐ، اﺗﺼﻞ‬
‫ﲟﻜﺘﺐ اﳋﺪﻣﺎت اﻷﺟﺘﻤﺎﻋﻴﺔ‬
:‫اﺳﻢ اﻷم ﻗﺒﻞ اﻟﺰواج‬
:‫اﻷﺧﻴﺮ‬
:‫اﻟﻮﺳﻂ‬
:‫اﻷول‬
.‫اﶈﻠﻲ‬
:‫اﺳﻢ اﻷب‬
:‫اﻷﺧﻴﺮ‬
:‫اﻟﻮﺳﻂ‬
:‫اﻷول‬
‫ﻗﺪ ﻻ ﻳﻜﻮن ﺑﺎﺳﺘﻄﺎﻋﺘﻨﺎ‬
) ‫رﻗﻢ ﺷﻬﺎدة اﳌﻴﻼد‬
:(‫اذا ﻛﻨﺖ ﺗﻌﺮﻓﻪ‬
‫اﳊﺼﻮل ﻋﻠﻰ ﺳﺠﻞ اﻟﻮﻻدة اﻟﺬي‬
‫ﺗﻄﻠﺒﻪ. اذا ﺣﺼﻞ ذﻟﻚ، ﻳﺠﺐ‬
‫ﻋﻠﻴﻚ ﺗﻘﺪﱘ وﺛﻴﻘﺔ اﺧﺮى ﻻﺛﺒﺎت‬
‫اﺳﻢ اﻟﺸﺨﺺ اﻟﺜﺎﻧﻲ اﻟﺬي‬
.‫اﳉﻨﺴﻴﺔ‬
:‫ﺗﺮﻳﺪ ﺳﺠﻞ وﻻدة ﻟﻪ‬
:‫اﻷﺧﻴﺮ‬
:‫اﻟﻮﺳﻂ‬
:‫اﻷول‬
،‫اذا ﻛﺎن ﻗﺪ ﰎ ﺗﺒﻨﻲ ﻫﺬا اﻟﺸﺨﺺ‬
‫اذا ﺣﺼﻠﻨﺎ ﻋﻰ ﺳﺠﻞ اﻟﻮﻻدة‬
:‫اﻛﺘﺐ اﺳﻢ اﻟﺘﺒﻨﻲ‬
:‫اﻷﺧﻴﺮ‬
:‫اﻟﻮﺳﻂ‬
:‫اﻷول‬
‫اﻟﺬي ﺗﻄﻠﺒﻪ، ﻻ ﻳﺰال ﻳﺠﺐ ﻋﻠﻴﻚ‬
.‫ﺗﻘﺪﱘ وﺛﻴﻘﺔ اﺛﺒﺎت ﻫﻮﻳﺔ‬
o
o
:‫اﳉﻨﺲ‬
‫اﻧﺜﻰ‬
‫ذﻛﺮ‬
‫ﻳﺤﺘﺎج ﻣﻜﺘﺐ اﳋﺪﻣﺎت اﻷﺟﺘﻤﺎﻋﻴﺔ‬
:‫ﺗﺎرﻳﺦ اﳌﻴﻼد‬
:‫اﻟﺴﻨﺔ‬
:‫اﻟﻴﻮم‬
:‫اﻟﺸﻬﺮ‬
‫ﻓﻲ اﳌﻘﺎﻃﻌﺔ اﳌﻌﻠﻮﻣﺎت اﳌﻄﻠﻮﺑﺔ‬
‫ﻟﻠﺒﺤﺚ ﻋﻦ ﺳﺠﻞ وﻻدة ﻓﻲ‬
:‫اﳌﻘﺎﻃﻌﺔ وﻣﺪﻳﻨﺔ اﳌﻴﻼد‬
:‫ﻣﻘﺎﻃﻌﺔ ﻛﺎﻟﻴﻔﻮرﻧﻴﺎ‬
:‫اﳌﺪﻳﻨﺔ‬
‫ﻛﺎﻟﻴﻔﻮرﻧﻴﺎ ﻷﺛﺒﺎت اﳉﻨﺴ ﻴ ّﺔ. اﻧﺖ‬
.‫ﻏﻴﺮ ﻣﻠﺰم ﺑﺘﻘﺪﱘ ﻫﺬه اﳌﻌﻠﻮﻣﺎت‬
:‫اﺳﻢ اﻷم ﻗﺒﻞ اﻟﺰواج‬
:‫اﻷﺧﻴﺮ‬
:‫اﻟﻮﺳﻂ‬
:‫اﻷول‬
‫وﻟﻜﻦ اذا ﻟﻢ ﺗﻔﻌﻞ، ﻗﺪ ﻻ ﻳﻜﻮن‬
:‫اﺳﻢ اﻷب‬
:‫اﻷﺧﻴﺮ‬
:‫اﻟﻮﺳﻂ‬
:‫اﻷول‬
‫ﺑﺎﺳﺘﻄﺎﻋﺔ اﳌﻘﺎﻃﻌﺔ اﻳﺠﺎد‬
.‫ﺳﺠﻞ اﻟﻮﻻدة‬
) ‫رﻗﻢ ﺷﻬﺎدة اﳌﻴﻼد‬
:(‫اذا ﻛﻨﺖ ﺗﻌﺮﻓﻪ‬
.‫اذا ﻛﻨﺖ ﺑﺤﺎﺟﺔ اﻟﻰ اﻛﺜﺮ ﻣﻦ ﺳﺠﻠﻲ وﻻدة، اﻣﻸ ﻃﻠﺐ اﺧﺮ‬
DHCS 0004 (06/07) – Arabic
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