Form Dhcs 0002 - California Proof Of Citizenship And Identity (Farsi) - Health And Human Services Agency Page 3

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State of California – Health and Human Services Agency
Department of Health Care Services
‫ﻣدارك ﻗﺎﺑل ﻗﺑول ﺳﻳﺗﻲ زن ﺷﻳﭘﻲ و ﻫوﻳت‬
:‫آﺳﺎن ﺗرﻳن راه ﺛﺎﺑت ﻛردن ﺳﻳﺗﻲ زن ﺷﻳﭘﻲ و ﻫوﻳت ﻫر دو، اراﺋﻪ ﻳﻛﻲ از اﻳن ﻣدارك اﺳت‬
‫ﭘﺎﺳﭘورت ﻫﺎى ﻣﻧﻘﺿﻲ ﺷده ﻗﺎﺑل ﻗﺑول ﻧﻳﺳﺗﻧد‬
‫ﭘﺎﺳﭘورت اﻳﺎﻻت ﻣﺗﺣده ﻛﻪ ﺑدون ﻣﺣدودﻳت ﺻﺎدر ﺷده ﺑﺎﺷد‬
(
)
—
‫ﻳﺎ‬
‫ﮔواﻫﻲ ﺗﺎﺑﻌﻳت‬
(N-570
N-550)
—
‫ﻳﺎ‬
‫ﮔواﻫﻲ ﺳﻳﺗﻲ زن ﺷﻳﭘﻲ اﻳﺎﻻت ﻣﺗﺣده‬
(N-561
N-560)
—
– ‫– ﻳﺎ‬
...‫اﮔﺮ ﺷﻤﺎ ﻳﻜﻲ از ﻣﺪارك ﺑﺎﻻ را ﻧﺪارﻳﺪ، آﻧﭽﻪ ﺑﺎﻳﺪ ﻋﺮﺿﻪ ﻛﻨﻴﺪ از اﻳﻦ ﻗﺮار اﺳﺖ‬
:‫ﻳك ﺳﻧد ﺳﻳﺗﻲ زن ﺷﻳﭘﻲ ﻟﻳﺳت ﺷده در زﻳر‬
‫❖ ﺳﺎﺑﻘﻪ آﻣﺎر ﻓدرال ﻳﺎ اﻳﺎﻟﺗﻲ ﻛﻪ ﺳن ﻣﺗﻘﺎﺿﻲ و ﺳﻳﺗﻲ زن ﺷﻳﭘﻲ‬
‫❖ ﮔواﻫﻲ ﺗوﻟد اﻳﺎﻻت ﻣﺗﺣده‬
‫اﻳﺎﻻت ﻣﺗﺣده ﻳﺎ ﻣﺣل ﺗوﻟد او را ﻧﺷﺎن ﻣﻲ دﻫد‬
‫❖ ﮔواﻫﻲ ﮔزارش ﺗوﻟد‬
(DS-1350)
*‫❖ ﺳﺎﺑﻘﻪ آﻣﺎر ﻗﺑﻳﻠﻪ اي ﺳرﺧﭘوﺳﺗﺎن ﺳﻧﻛﺎ‬
†
‫❖ ﮔزارش ﺗوﻟد ﺳﻳﺗﻲ زن اﻳﺎﻻت ﻣﺗﺣده در ﺧﺎرج از اﻳن ﻛﺷور‬
(FS-240)
†
*‫❖ ﺳﺎﺑﻘﻪ آﻣﺎر دﻓﺗر اﻣور ﺳرﺧﭘوﺳﺗﺎن ﻣﺗﻌﻠق ﺑﻪ ﻗﺑﺎﺋل ﻧﺎواﻫو‬
‫❖ ﮔواﻫﻲ ﺗوﻟد ﺻﺎدر ﺷده ﺗوﺳط وزارت اﻣور ﺧﺎرﺟﻪ اﻳﺎﻻت ﻣﺗﺣده‬
‫❖ ﮔواﻫﻲ ﺗوﻟد ﺻﺎدره در ﻫر ﻳك از اﻳﺎﻟت ﻫﺎي اﻳﺎﻻت ﻣﺗﺣده ﻛﻪ در‬
‫ﻳﺎ‬
(DS-1350
FS-545)
*‫اداره آﻣﺎرﻫﺎي ﻧﻔوس آﻧﻬﺎ ﺛﺑت ﺷده‬
†
‫ﻳﺎ‬
‫❖ ﻛﺎرت ﻫوﻳت ﺳﻳﺗﻲ زن ﺷﻳﭘﻲ اﻳﺎﻻت ﻣﺗﺣده‬
(I-179
I-197)
‫ﻛﻪ ﺑﻳش از‬
‫❖ ﺳﺎﺑﻘﻪ ﺗوﻟد ﺑﻪ ﺗﻌوﻳق اﻓﺗﺎده ﻋﻣوﻣﻲ اﻳﺎﻻت ﻣﺗﺣده‬
5
)
‫❖ ﻛﺎرت ﺳرﺧﭘوﺳﺗﺎن آﻣرﻳﻛﺎ‬
(I-872)
*
‫ﺳﺎل ﭘس از ﺗوﻟد ﺷﺧص ﺑﻪ ﺛﺑت رﺳﻳده ﺑﺎﺷد‬
†
(
‫❖ ﻛﺎرت ﻣﺎرﻳﺎﻧﺎي ﺷﻣﺎﻟﻲ‬
(I-873)
‫❖ ﺑﻳﺎﻧﻪ اﻣﺿﺎ ﺷده ﺗوﺳط ﭘزﺷك ﻳﺎ ﻣﺎﻣﺎﺋﻲ ﻛﻪ ﻫﻧﮕﺎم ﺗوﻟد ﺣﺿور‬
‫❖ آﺧرﻳن دﺳﺗور دادﮔﺎﻫﻲ ﻓرزﻧد ﺧواﻧدﮔﻲ ﻛﻪ ﻣﺣل ﺗوﻟد در اﻳﺎﻻت‬
*‫داﺷﺗﻪ اﺳت‬
†
‫ﻣﺗﺣده را ﻧﺷﺎن دﻫد‬
†
*‫❖ ﻟﻳﺳت رﺳﻣﻲ اﺳﺎﻣﻲ ﺑوﻣﻳﺎن آﻻﺳﻛﺎ از اداره اﻣور ﺳرﺧﭘوﺳﺗﺎن‬
‫❖ ﺳﻧد ﻣرﺑوط ﺑﻪ ﭘذﻳرﻓﺗﻪ ﺷدن ﺑﻪ ﻓرزﻧد ﺧواﻧدﮔﻲ ﻛودﻛﻲ ﻛﻪ در‬
،‫❖ اوراق ﭘذﻳرش از ﻳﻛﻲ از ﺗﺄﺳﻳﺳﺎت ﭘرﺳﺗﺎري ﻳﺎ ﻣراﻗﺑت ﻫﺎي وﻳژه‬
‫ﺧﺎرج از اﻳﺎﻻت ﻣﺗﺣده ﺑدﻧﻳﺎ آﻣده و ﺗﺣت ﺳرﭘرﺳﺗﻲ ﻗﺎﻧوﻧﻲ/ﻓﻳزﻳﻛﻲ‬
*‫ﻳﺎ ﺳﺎﻳر ﻣؤﺳﺳﺎﺗﻲ ﻛﻪ ﻣﺣل ﺗوﻟد در اﻳﺎﻻت ﻣﺗﺣده را ﻧﺷﺎن دﻫد‬
‫ﻳﺎ‬
‫واﻟدي اﺳت ﻛﻪ ﺷﻬروﻧد اﻳﺎﻻت ﻣﺗﺣده اﺳت‬
(IR-4
IR-3)
*
‫ﺑﺟز ﺳواﺑق واﻛﺳﻳﻧﺎﺳﻳون‬
‫❖ ﺳواﺑق ﭘزﺷﻛﻲ‬
†
(
)
‫❖ ﺳﻧد اﺳﺗﺧداﻣﻲ ﺧدﻣﺎت ﻣدﻧﻲ اﻳﺎﻻت ﻣﺗﺣده ﻣرﺑوط ﺑﻪ ﻗﺑل از‬
1
‫ﺟون‬
‫ﺳﺎل ﻗﺒﻞ از زﻣﺎﻧﻲ ﺑﺎﺷﺪ ﻛﻪ ﺑﺮاي ﻧﺨﺴﺘﻴﻦ ﺑﺎر‬
‫* ﺗﺎرﻳﺦ آن ﺑﺎﻳﺪ ﺣﺪاﻗﻞ‬
1976
5
‫ﺗﻘﺎﺿﺎ ﻣﻲ دﻫﻴﺪ و ﻣﺤﻞ ﺗﻮﻟﺪ در اﻳﺎﻻت ﻣﺘﺤﺪه را ﻧﺸﺎن دﻫﺪ. ﺑﺮاي‬
‫ﺑﺮاي‬
Medi-Cal
‫❖ ﻣدرك ﺧدﻣت ﻧظﺎﻣﻲ اﻳﺎﻻت ﻣﺗﺣده ﻛﻪ ﻣﺣل ﺗوﻟد در اﻳﺎﻻت ﻣﺗﺣده‬
.‫ﺳﺎل ﺑﺎﻳﺪ ﻛﻪ ﻧﺰدﻳﻚ ﺑﻪ زﻣﺎن ﺗﻮﻟﺪ ﺗﻬﻴﻪ ﺷﺪه ﺑﺎﺷﺪ‬
‫ﻛﻮدﻛﺎن زﻳﺮ‬
16
†
‫را ﻧﺷﺎن ﻣﻲ دﻫد‬
*‫❖ ﻣدرك ﺑﻳﻣﺎرﺳﺗﺎﻧﻲ اﻳﺎﻻت ﻣﺗﺣده ﻛﻪ در زﻣﺎن ﺗوﻟد ﻧوﺷﺗﻪ ﺷده ﺑﺎﺷد‬
†
‫ﺷﻣﺎ ﺑﺎﻳد در ﺣد اﻣﻛﺎن ﻣدرﻛﻲ را اراﺋﻪ دﻫﻳد ﻛﻪ در ﻗﺳﻣت ﺑﺎﻻﺗري از اﻳن‬
.‫ﻟﻳﺳت ﻗرار دارد‬
†
*‫❖ ﺑﻳﻣﻪ ﻋﻣر، ﺑﻬداﺷﺗﻲ، ﻳﺎ ﺳﺎﻳر ﺳواﺑق ﻣﺷﺎﺑﻪ ﺑﻳﻣﻪ‬
‫ﻣﺎه ﭘس از ﺗوﻟد‬
‫❖ ﺳﻧد ﻣذﻫﺑﻲ ﺛﺑت ﺷده در اﻳﺎﻻت ﻣﺗﺣده در ﻋرض‬
...‫اﮔر ﺷﻣﺎ ﻧﻣﻲ ﺗواﻧﻳد ﻫﻳﭼﻛدام از اﻳن ﻣدارك ﺳﻳﺗﻲ زن ﺷﻳپ را اراﺋﻪ دﻫﻳد‬
3
‫ﻛﻪ ﻣﺣل ﺗوﻟد در اﻳﺎﻻت ﻣﺗﺣده و ﺗﺎرﻳﺦ ﺗوﻟد ﻳﺎ ﺳن را ﻧﺷﺎن ﻣﻲ دﻫد‬
‫او دو ﺑزرﮔﺳﺎل ﺑﺧواﻫﻳد ﻳك اظﻬﺎرﻧﺎﻣﻪ ﺳﻳﺗﻲ زن ﺷﻳﭘﻲ‬
،‫❖ ﺳﻧد ﻣدرﺳﻪ اوﻟﻳﻪ ﻛﻪ ﻣﺣل ﺗوﻟد در اﻳﺎﻻت ﻣﺗﺣده، ﺗﺎرﻳﺦ ﭘذﻳرش‬
‫را ﭘر ﻛرده و اﻣﺿﺎء ﻧﻣﺎﻳﻧد. ﻫر دو‬
(Affidavit of Citizenship)
‫ﺗﺎرﻳﺦ ﺗوﻟد، و ﻧﺎم و ﻣﺣل ﺗوﻟد واﻟدﻳن را ﻧﺷﺎن ﻣﻲ دﻫد‬
‫ﺑزرﮔﺳﺎل ﺧود ﺑﺎﻳد داراي ﺳﻧد ﻫوﻳت و ﺳﻳﺗﻲ زن ﺷﻳﭘﻲ اﻳﺎﻻت ﻣﺗﺣده‬
.‫ﺑوده و ﺗﻧﻬﺎ ﻳﻛﻲ از آﻧﻬﺎ ﻣﻲ ﺗواﻧد ﺑﺎ ﺷﻣﺎ ﻧﺳﺑت ﺧﺎﻧوادﮔﻲ داﺷﺗﻪ ﺑﺎﺷد‬
‫و‬
–
–
:‫ﻳك ﺳﻧد ﻫوﻳت ﻟﻳﺳت ﺷده در زﻳر‬
‫❖ ﻛﺎرت ﺷﻧﺎﺳﺎﺋﻲ دوﻟت ﻓدرال، اﻳﺎﻟﺗﻲ ﻳﺎ ﻣﺣﻠﻲ ﺑﺎ ﻫﻣﺎن اطﻼﻋﺎت‬
‫❖ ﮔواﻫﻳﻧﺎﻣﻪ راﻧﻧدﮔﻲ ﺻﺎدر ﺷده ﺗوﺳط ﻳك اﻳﺎﻟت ﻳﺎ ﻗﻠﻣرو اﻳﺎﻻت‬
‫ﺷﻧﺎﺳﺎﺋﻲ ﻣرﺑوط ﺑﻪ ﮔواﻫﻳﻧﺎﻣﻪ راﻧﻧدﮔﻲ‬
‫ﻣﺗﺣده ﻫﻣراه ﺑﺎ ﻋﻛس ﻳﺎ ﺳﺎﻳر اطﻼﻋﺎت ﻣرﺑوط ﺑﻪ ﺷﻧﺎﺳﺎﺋﻲ‬
‫❖ ﻛﺎرت ﺷﻧﺎﺳﺎﺋﻲ ارﺗش اﻳﺎﻻت ﻣﺗﺣده ﻣرﺑوط ﺑﻪ ﺷﺧص واﺑﺳﺗﻪ‬
‫❖ ﻛﺎرت ﺷﻧﺎﺳﺎﺋﻲ ﻋﻛﺳدار ﻣﺣل ﺗﺣﺻﻳل‬
‫ﺻﺎدر ﺷده ﺑﺎ ﻣﺣدودﻳت‬
‫❖ ﭘﺎﺳﭘورت اﻳﺎﻻت ﻣﺗﺣده‬
‫❖ ﻛﺎرت ﺷﻧﺎﺳﺎﺋﻲ ﻧظﺎﻣﻲ اﻳﺎﻻت ﻣﺗﺣده ﻳﺎ ﺳﺎﺑﻘﻪ اﺣﺿﺎر ﺑﻪ ﺧدﻣت ﻧظﺎم‬
(
)
‫اداﻣﻪ در ﭘﺷت ﺻﻔﺣﻪ‬
DHCS 0002 (01/08) – Farsi
Page 3 of 4

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