Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (Armenian) - Health And Human Services Agency
ADVERTISEMENT
1State of California – Health and Human Services Agency
Department of Health Care Services
ø³Õ³ù³óÇáõÃÛáõÝÁ ¢ ÇÝùÝáõÃÛáõÝÁ ѳëï³ïáÕ
ÁݹáõÝ»ÉÇ ÷³ëï³ÃÕûñÇ ³å³óáõÛó
Àëï Ýáñ ûñ»ÝùÇ, Medi-Cal-Ç ¹ÇÙáñ¹Ý»ñÇ ¢ Ýå³ëï³éáõÝ»ñÇ Ù»Í³Ù³ëÝáõÃÛáõÝÁ, áíù»ñ ²ØÜ-Ç ù³Õ³ù³óÇ
ϳ٠Ñå³ï³Ï »Ý, å»ïù ¿ Ý»ñϳ۳óÝ»Ý Çñ»Ýó ù³Õ³ù³óÇáõÃÛáõÝÁ ¢ ÇÝùÝáõÃÛáõÝÁ ѳëï³ïáÕ ³å³óáõÛó:
ì³ñã³ßñç³ÝÁ ëï³ó»É ¢ í»ñ³Ý³Û»É ¿ ù³Õ³ù³óÇáõÃÛáõÝÁ ¢/ϳ٠ÇÝùÝáõÃÛáõÝÁ ѳëï³ïáÕ ³å³óáõÛóÁ,
áñÁ ¸áõù Ý»ñϳ۳óñ»É »ù Ñ»ï¢Û³É ³ÝÓÇ Ñ³Ù³ñ.
¸ÇÙáñ¹Ç ϳ٠Ýå³ëï³éáõÇ ³ÝáõÝÁ.
²ÝáõÝ
ØÇçÇÝ ³ÝáõÝ
²½·³ÝáõÝ
ÌÝÝ¹Û³Ý ³Ùë³ÃÇíÁ ¢ ï³ñÇÝ.
Üß»ù ù³Õ³ù³óÇáõÃÛ³Ý ÷³ëï³ÃáõÕÃÁ, áñÁ
Üß»ù ÇÝùÝáõÃÛ³Ý ÷³ëï³ÃáõÕÃÁ, áñÁ ¸áõù
¸áõù ï»ë³ù.
ï»ë³ù.
гëï³ïáõÙ: Ò»ñ Ý»ñϳ۳óñ³Í
гëï³ïáõÙ: Ò»ñ Ý»ñϳ۳óñ³Í ÇÝùÝáõÃÛ³Ý
ù³Õ³ù³óÇáõÃÛ³Ý ÷³ëï³ÃáõÕÃÁ ϳ۳ÝáõÙ
÷³ëï³ÃáõÕÃÁ ϳ۳ÝáõÙ ¿ Ò»ñ ÇÝùÝáõÃÛáõÝÁ
¿ Ò»ñ ù³Õ³ù³óÇáõÃÛ³Ý ÁݹáõÝ»ÉÇ ³å³óáõÛó:
ѳëï³ïáÕ ÁݹáõÝ»ÉÇ ³å³óáõÛó: ¸áõù ³ÛÉ¢ë
¸áõù ³ÛÉ¢ë ϳñÇù ãáõÝ»ù Ý»ñϳ۳óÝ»É ³ÛÉ
ϳñÇù ãáõÝ»ù Ý»ñϳ۳óÝ»É ³ÛÉ ³å³óáõÛó
³å³óáõÛó í»ñáÑÇßÛ³É ³ÝÓÇ Ñ³Ù³ñ:
í»ñáÑÇßÛ³É ³ÝÓÇ Ñ³Ù³ñ:
Ø»ñÅáõÙ: Ò»ñ Ý»ñϳ۳óñ³Í ³å³óáõÛóÝ
Ø»ñÅáõÙ: Ò»ñ Ý»ñϳ۳óñ³Í ÇÝùÝáõÃÛáõÝÁ
ÁݹáõÝ»ÉÇ ã¿: ¸áõù å»ïù ¿ Ý»ñϳ۳óÝ»ù
ѳëï³ïáÕ ³å³óáõÛóÝ ÁݹáõÝ»ÉÇ ã¿: ¸áõù
ù³Õ³ù³óÇáõÃÛáõÝÝ ³å³óáõóáÕ Ù»Ï ³ÛÉ
å»ïù ¿ Ý»ñϳ۳óÝ»ù ÇÝùÝáõÃÛáõÝÁ ѳëï³ïáÕ
÷³ëï³ÃáõÕÃ: ÎÇó Ýßí³Í ¿ ù³Õ³ù³óÇáõÃÛáõÝÝ
Ù»Ï ³ÛÉ ³å³óáõÛó: ÎÇó Ýßí³Í ¿ ÇÝùÝáõÃÛáõÝÝ
³å³óáõóáÕ ÁݹáõÝ»ÉÇ ÷³ëï³ÃÕûñÇ óáõó³Ï:
³å³óáõóáÕ ÁݹáõÝ»ÉÇ ÷³ëï³ÃÕûñÇ óáõó³Ï:
• ´áÉáñ ÷³ëï³ÃÕûñÁ å»ïù ¿ ÉÇÝ»Ý
• ´áÉáñ ÷³ëï³ÃÕûñÁ å»ïù ¿ ÉÇÝ»Ý
μÝûñÇݳÏÝ»ñ ϳ٠ÁÝÓ»éáÕ ·áñͳϳÉáõÃÛ³Ý
μÝûñÇݳÏÝ»ñ ϳ٠ÁÝÓ»éáÕ ·áñͳϳÉáõÃÛ³Ý
ÏáÕÙÇó ѳí³ëï³·ñí³Í å³ï×»ÝÝ»ñ:
ÏáÕÙÇó ѳí³ëï³·ñí³Í å³ï×»ÝÝ»ñ:
üáïáå³ï×»ÝÝ»ñÝ ÁݹáõÝ»ÉÇ ã»Ý:
üáïáå³ï×»ÝÝ»ñÝ ÁݹáõÝ»ÉÇ ã»Ý:
ì»ñáÑÇßÛ³É ³ÝÓÁ μ³í³ñ³ñáõÙ ¿ ù³Õ³ù³óÇáõÃÛ³Ý ¢ ÇÝùÝáõÃÛ³Ý Ýáñ å³Ñ³ÝçÝ»ñÁ, ù³ÝÇ áñ Ýñ³
ù³Õ³ù³óÇáõÃÛ³Ý ¢ ÇÝùÝáõÃÛ³Ý ÷³ëï³ÃÕûñÁ ѳëï³ïí»É »Ý:
ì»ñáÑÇßÛ³É ³ÝÓÁ ãÇ μ³í³ñ³ñáõÙ ù³Õ³ù³óÇáõÃÛ³Ý ¢ ÇÝùÝáõÃÛ³Ý Ýáñ å³Ñ³ÝçÝ»ñÁ, ù³ÝÇ áñ Ýñ³
ù³Õ³ù³óÇáõÃÛ³Ý ¢ ÇÝùÝáõÃÛ³Ý ÷³ëï³ÃÕûñÇó Ù»ÏÁ ϳ٠»ñÏáõëÝ ¿É Ù»ñÅí»É »Ý ϳ٠ã»Ý Ý»ñϳ۳óí»É:
ºÃ» áñ¢¿ ѳñó áõÝ»ù, ËݹñáõÙ »Ýù Ñ»é³Ó³ÛÝ»É Ò»ñ í³ñã³ßñç³ÝÇ Ñ³ë³ñ³Ï³Ï³Ý ͳé³ÛáõÃÛáõÝÝ»ñÇ
·ñ³ë»Ý۳Ϫ ëïáñ¢ Ýßí³Í Ñ»é³Ëáë³Ñ³Ù³ñáí:
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) – Armenian
Page 1 of 1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (spanish) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (hmong) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (arabic) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (chinese) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (korean) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (laotian) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (russian) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (vietnamese) - Health And Human Services Agency
Legal
Related Categories
Parent category: Legal