State of California – Health and Human Services Agency
Department of Health Care Services
•
•
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) – Korean
Page 1 of 1