Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (Arabic) - Health And Human Services Agency
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1State of California – Health and Human Services Agency
Department of Health Care Services
ﺍﻟﻮﺛﺎﺋﻖ ﺍﳌﻘﺒﻮﻟﺔ ﻹﺛﺒﺎﺕ ﺍﳉﻨﺴﻴﺔ ﺃﻭ ﺍﻟﻬﻮﻳﺔ
Medi-Cal
ﻣﻦ ﺍﳌﻮﺍﻃﻨﲔ ﺍﻷﻣﺮﻳﻜﻴﲔ ﺃﻭ ﺣﺎﻣﻠﻲ ﺍﳉﻨﺴﻴﺔ
ﻗﺎﻧﻮﻥ ﺟﺪﻳﺪ ﻳﻨﺺ ﻋﻠﻰ ﺃﻥ ﻣﻌﻈﻢ ﻣﻘﺪﻣﻲ ﺍﻟﻄﻠﺒﺎﺕ ﻭﺍﳌﺴﺘﻔﻴﺪﻳﻦ ﻣﻦ ﺑﺮﻧﺎﻣﺞ
.ﺍﻷﻣﺮﻳﻜﻴﺔ ﻳﺠﺐ ﻋﻠﻴﻬﻢ ﺗﻘﺪﱘ ﻭﺛﺎﺋﻖ ﻹﺛﺒﺎﺕ ﺍﳉﻨﺴﻴﺔ ﻭﺍﻟﻬﻮﻳﺔ
:ﺍﳌﻘﺎﻃﻌﺔ ﻗﺪ ﺗﻠﻘﺖ ﻭﺭﺍﺟﻌﺖ ﻭﺛﺎﺋﻖ ﺇﺛﺒﺎﺕ ﺍﳉﻨﺴﻴﺔ ﻭ/ﺃﻭ ﺍﻟﻬﻮﻳﺔ ﺍﻟﺘﻲ ﻗﺪﻣﺘﻬﺎ ﻋﻦ
:ﺇﺳﻢ ﻣﻘﺪﻡ ﺍﻟﻄﻠﺐ ﺃﻭ ﺍﳌﺴﺘﻔﻴﺪ
ﺍﻷﺧﻴﺮ
ﺍﻷﻭﺳﻂ
ﺍﻷﻭﻝ
:ﺗﺎﺭﻳﺦ ﺍﳌﻴﻼﺩ
:ﺇﺳﻢ ﻭﺛﻴﻘﺔ ﺍﻟﻬﻮﻳﺔ ﺍﻟﺘﻲ ﺭﺃﻳﺘﻬﺎ
:ﺇﺳﻢ ﻭﺛﻴﻘﺔ ﺍﳉﻨﺴﻴﺔ ﺍﻟﺘﻲ ﺭﺃﻳﺘﻬﺎ
.ﻣﻘﺒﻮﻝ. ﻭﺛﻴﻘﺔ ﺍﻟﻬﻮﻳﺔ ﺍﻟﺘﻲ ﻗﺪﻣﺘﻬﺎ ﻫﻲ ﺇﺛﺒﺎﺕ ﻣﻘﺒﻮﻝ ﻟﻠﻬﻮﻳﺔ
ﻣﻘﺒﻮﻝ. ﻭﺛﻴﻘﺔ ﺍﳉﻨﺴﻴﺔ ﺍﻟﺘﻲ ﻗﺪﻣﺘﻬﺎ ﻫﻲ ﺇﺛﺒﺎﺕ ﻣﻘﺒﻮﻝ
.ﻟﻦ ﻳﻜﻮﻥ ﻋﻠﻴﻚ ﺗﻘﺪﱘ ﺍﻹﺛﺒﺎﺕ ﻣﺮﺓ ﺃﺧﺮﻯ ﻟﻠﺸﺨﺺ ﺍﳌﺬﻛﻮﺭ ﺃﻋﻼﻩ
ﻟﻠﺠﻨﺴﻴﺔ. ﻟﻦ ﻳﻜﻮﻥ ﻋﻠﻴﻚ ﺗﻘﺪﱘ ﺍﻹﺛﺒﺎﺕ ﻣﺮﺓ ﺃﺧﺮﻯ ﻟﻠﺸﺨﺺ
.ﺍﳌﺬﻛﻮﺭ ﺃﻋﻼﻩ
ﻣﺮﻓﻮﺽ. ﻭﺛﻴﻘﺔ ﺍﻟﻬﻮﻳﺔ ﺍﻟﺘﻲ ﻗﺪﻣﺘﻬﺎ ﻏﻴﺮ ﻣﻘﺒﻮﻟﺔ. ﻳﺠﺐ ﻋﻠﻴﻚ
ﺗﻘﺪﱘ ﺇﺛﺒﺎﺕ ﺁﺧﺮ ﻟﻠﻬﻮﻳﺔ. ﻣﺮﻓﻖ ﻗﺎﺋﻤﺔ ﻟﻮﺛﺎﺋﻖ ﺇﺛﺒﺎﺕ ﺍﻟﻬﻮﻳﺔ
ﻣﺮﻓﻮﺽ. ﺍﻹﺛﺒﺎﺕ ﺍﻟﺬﻱ ﻗﺪﻣﺘﻪ ﻏﻴﺮ ﻣﻘﺒﻮﻝ. ﻳﺠﺐ ﻋﻠﻴﻚ ﺗﻘﺪﱘ
.ﺍﳌﻘﺒﻮﻟﺔ
.ﺇﺛﺒﺎﺕ ﺁﺧﺮ ﻟﻠﺠﻨﺴﻴﺔ. ﻣﺮﻓﻖ ﻗﺎﺋﻤﺔ ﻟﻮﺛﺎﺋﻖ ﺇﺛﺒﺎﺕ ﺍﳉﻨﺴﻴﺔ ﺍﳌﻘﺒﻮﻟﺔ
ﻛﻞ ﺍﻟﻮﺛﺎﺋﻖ ﻳﺠﺐ ﺃﻥ ﺗﻜﻮﻥ ﺃﺻﻠﻴﺔ ﺃﻭ ﻧﺴﺦ ﻣﺼﺪﻗﺔ ﻣﻦ
ﻛﻞ ﺍﻟﻮﺛﺎﺋﻖ ﻳﺠﺐ ﺃﻥ ﺗﻜﻮﻥ ﺃﺻﻠﻴﺔ ﺃﻭ ﻧﺴﺦ ﻣﺼﺪﻗﺔ ﻣﻦ
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.ﺟﻬﺔ ﺍﻹﺻﺪﺍﺭ. ﺍﻟﺼﻮﺭ ﺍﳌﻨﺴﻮﺧﺔ ﻏﻴﺮ ﻣﻘﺒﻮﻟﺔ
.ﺟﻬﺔ ﺍﻹﺻﺪﺍﺭ. ﺍﻟﺼﻮﺭ ﺍﳌﻨﺴﻮﺧﺔ ﻏﻴﺮ ﻣﻘﺒﻮﻟﺔ
.ﺍﻟﺸﺨﺺ ﺍﳌﺬﻛﻮﺭ ﺃﻋﻼﻩ ﻗﺪ ﺇﺳﺘﻮﻓﻰ ﺍﳌﺘﻄﻠﺒﺎﺕ ﺍﳉﺪﻳﺪﺓ ﻹﺛﺒﺎﺕ ﺍﳉﻨﺴﻴﺔ ﻭﺍﻟﻬﻮﻳﺔ ﺣﻴﺚ ﺃﻧﻪ ﻗﺪ ﰎ ﻗﺒﻮﻝ ﻛﻞﹴ ﻣﻦ ﻭﺛﺎﺋﻖ ﺍﳉﻨﺴﻴﺔ ﻭﺍﻟﻬﻮﻳﺔ
ﺍﻟﺸﺨﺺ ﺍﳌﺬﻛﻮﺭ ﺃﻋﻼﻩ ﻟﻢ ﻳﺴﺘﻮﻓﻲ ﺍﳌﺘﻄﻠﺒﺎﺕ ﺍﳉﺪﻳﺪﺓ ﻹﺛﺒﺎﺕ ﺍﳉﻨﺴﻴﺔ ﻭﺍﻟﻬﻮﻳﺔ ﺣﻴﺚ ﺃﻧﻪ ﻟﻢ ﻳﺘﻢ ﺗﻘﺪﱘ ﺃﻭ ﻗﺪ ﰎ ﺭﻓﺾ ﺇﺣﺪﻯ ﺃﻭ ﻛﻞﹴ ﻣﻦ
.ﻭﺛﺎﺋﻖ ﺍﳉﻨﺴﻴﺔ ﻭ/ﺃﻭ ﺍﻟﻬﻮﻳﺔ
.ﺇﺫﺍ ﻛﺎﻧﺖ ﻟﺪﻳﻚ ﺇﺳﺘﻔﺴﺎﺭﺍﺕ، ﺍﻟﺮﺟﺎﺀ ﺍﻹﺗﺼﺎﻝ ﲟﻜﺘﺐ ﺍﳋﺪﻣﺎﺕ ﺍﻹﺟﺘﻤﺎﻋﻴﺔ ﳌﻘﺎﻃﻌﺘﻚ ﻋﻠﻰ ﺭﻗﻢ ﺍﻟﺘﻠﻔﻮﻥ ﺍﳌﺪﺭﺝ ﺃﺩﻧﺎﻩ
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) – Arabic
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