Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (Vietnamese) - Health And Human Services Agency
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1State of California – Health and Human Services Agency
Department of Health Care Services
Baè n g chöù n g Vaê n Kieä n Quoá c Tòch vaø Caê n Cöôù c Ñöôï c Chaá p Nhaä n
Moä t luaä t môù i noù i raè n g haà u heá t nhöõ n g ngöôø i noä p ñôn xin vaø höôû n g phuù c lôï i Medi-Cal maø laø coâ n g daâ n hoaë c
cö daâ n Hoa Kyø thì phaû i ñöa ra baè n g chöù n g veà quoá c tòch vaø caê n cöôù c .
Quaä n ñaõ nhaä n vaø duyeä t baè n g chöù n g veà quoá c tòch vaø / hoaë c caê n cöôù c maø quyù vò ñaõ noä p cho:
Teâ n Ngöôø i Noä p Ñôn hoaë c Höôû n g Phuù c Lôï i :
Teâ n
Teâ n Loù t
Hoï
Ngaø y sinh:
Teâ n vaê n kieä n quoá c tòch quyù vò thaá y :
Teâ n vaê n kieä n caê n cöôù c quyù vò thaá y :
Chaá p Thuaä n . Vaê n kieä n quoá c tòch quyù vò ñaõ noä p
Chaá p Thuaä n . Vaê n kieä n caê n cöôù c quyù vò ñaõ noä p
ñöôï c chaá p nhaä n laø baè n g chöù n g veà quoá c tòch.
ñöôï c chaá p nhaä n laø baè n g chöù n g veà caê n cöôù c .
Quyù vò seõ khoâ n g phaû i ñöa ra baè n g chöù n g moä t
Quyù vò seõ khoâ n g phaû i ñöa ra baè n g chöù n g moä t
laà n nöõ a cho ngöôø i coù teâ n ôû treâ n .
laà n nöõ a cho ngöôø i coù teâ n ôû treâ n .
Töø Choá i . Baè n g chöù n g quyù vò ñaõ noä p khoâ n g
Töø Choá i . Vaê n kieä n caê n cöôù c quyù vò ñaõ noä p
ñöôï c chaá p nhaä n . Quyù vò phaû i noä p moä t baè n g
khoâ n g ñöôï c chaá p nhaä n . Quyù vò phaû i noä p moä t
chöù n g khaù c veà quoá c tòch. Ñính keø m laø danh
baè n g chöù n g khaù c veà caê n cöôù c . Ñính keø m laø
saù c h vaê n kieä n ñöôï c chaá p nhaä n laø m baè n g chöù n g
danh saù c h vaê n kieä n ñöôï c chaá p nhaä n laø m baè n g
quoá c tòch.
chöù n g caê n cöôù c .
• Taá t caû vaê n kieä n phaû i laø baû n chính hoaë c baû n
• Taá t caû vaê n kieä n phaû i laø baû n chính hoaë c baû n
sao coù chöù n g thöï c töø cô quan caá p phaù t .
sao coù chöù n g thöï c töø cô quan caá p phaù t .
Baû n töï sao chuï p khoâ n g ñöôï c chaá p nhaä n .
Baû n töï sao chuï p khoâ n g ñöôï c chaá p nhaä n .
Ngöôø i coù teâ n ôû treâ n ñaõ hoä i ñuû caù c ñieà u kieä n môù i veà quoá c tòch vaø caê n cöôù c vì caû hai vaê n kieä n quoá c tòch
vaø caê n cöôù c ñeà u ñöôï c chaá p thuaä n .
Ngöôø i coù teâ n ôû treâ n chöa hoä i ñuû caù c ñieà u kieä n môù i veà quoá c tòch vaø caê n cöôù c vì moä t hoaë c caû hai vaê n
kieä n quoá c tòch vaø / hoaë c caê n cöôù c ñeà u bò töø choá i hoaë c chöa noä p .
Neá u quyù vò coù thaé c maé c , xin lieâ n laï c vôù i vaê n phoø n g dòch vuï xaõ hoä i ôû quaä n quyù vò taï i soá ñieä n thoaï i lieä t keâ
döôù i ñaâ y .
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) – Vietnamese
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