Form Dhcs 0006 - California Proof Of Citizenship Or Identity Needed (Laotian) - Health And Human Services Agency

State of California – Health and Human Services Agency

Department of Health Care Services

8h v C,u g vdtlko1a h C 1n o dkogxa o rq o ]tg,n v Cc]t1a h C 1n o 8q ; [5 d 7q o

le]a [ z6 h I h v C0=

c]tz6 h I a [ zq o xt3spf

Medi-Cal

-b j C gxa o rq o ]tg,n v C s^ n x t-k-q o -k;ltstia 4

dq f \kp.\j g ;q h k ;j k z6 h I h v C0= c]tz6 h I a [ zq o xt3spf

lj ; os^ k p -b j C gxa o rq o ]tg,n v Cs^ n x t-k-q o ltstia 4 8h v CltcfCs^ a d 4ko1a h C 1n o dkogxa o rq o ]tg,n v C

Medi-Cal

c]t1a h C 1n o 8q ; [5 d 7q o D dti5 o k9a f skgvdtlko.o0= h m u j \ kpw;h 0 h k C]5 j , ou h 3 fp[+ . sh d kp

-n j 0 vCz6 h I h v C0= s^ n z 6 h I a [ zq o xt3spf

( -n j

-n j d kC

ok,ltd5 o ):

–

–

[5 d 7q o ou h 4 n d pq d g;a h o s^ n , u g Cn j v ow07q [ 8k,0= h d eoq f D r;dgIq k [+ 8 h v Cdkogvdtlko1a h C 1n o .fM vu d D

dti5 o k9a f sks^ a d 4ko1a h C 1n o 8q ; [5 d 7q o le]a [ [5 d 7q o ou h D

dti5 o k9a f sks^ a d 4ko1a h C 1n o dkogxa o rq o ]tg,n v C0vC[5 d 7q o ou h D

dti5 o k9a f sks^ a d 4ko1a h C 1n o dkogxa o rq o ]tg,n v C c]tsa ^ d 4ko1a h C 1n o 8q ; [5 d 7q o le]a [ [5 d 7q o ou h D

r;dgIq k [+ l k,kfsk[a o mb d dkogdu f 0vC[5 d 7q o ou h w fh D 4h k ;j k [5 d 7q o ou h g du f .oia 4 7k]y 2 = g oa P F dti5 o kxtdv[2v,

7eIh v C0= g vq k [a o mb d dkogdu f .oia 4 7k]y 2 = g oa P mu j 7 a f 8y f ,koc]tlq j C da [ 7n o ,kD

-n j 0 vCz6 h I h v C0= s^ n z 6 h I a [ zq o xt3spf

( -n j

-n j d kC

ok,ltd5 o ):

–

–

[5 d 7q o ou h 4 n d pq d g;a h o s^ n , u g Cn j v ow07q [ 8k,0= h d eoq f D r;dgIq k [+ 8 h v Cdkogvdtlko1a h C 1n o .fM vu d D

dti5 o k9a f sks^ a d 4ko1a h C 1n o 8q ; [5 d 7q o le]a [ [5 d 7q o ou h D

dti5 o k9a f sks^ a d 4ko1a h C 1n o dkogxa o rq o ]tg,n v C0vC[5 d 7q o ou h D

dti5 o k9a f sks^ a d 4ko1a h C 1n o dkogxa o rq o ]tg,n v C c]tsa ^ d 4ko1a h C 1n o 8q ; [5 d 7q o le]a [ [5 d 7q o ou h D

r;dgIq k [+ l k,kfsk[a o mb d dkogdu f 0vC[5 d 7q o ou h w fh D 4h k ;j k [5 d 7q o ou h g du f .oia 4 7k]y 2 = g oa P F dti5 o kxtdv[2v,

7eIh v C0= g vq k [a o mb d dkogdu f .oia 4 7k]y 2 = g oa P mu j 7 a f 8y f ,kou h c ]tlq j C da [ 7n o ,kD

-n j 0 vCz6 h I h v C0= s^ n z 6 h I a [ zq o xt3spf

( -n j

-n j d kC

ok,ltd5 o ):

–

–

[5 d 7q o ou h 4 n d pq d g;a h o s^ n , u g Cn j v ow07q [ 8k,0= h d eoq f D r;dgIq k [+ 8 h v Cdkogvdtlko1a h C 1n o .fM vu d D

dti5 o k9a f sks^ a d 4ko1a h C 1n o 8q ; [5 d 7q o le]a [ [5 d 7q o ou h D

dti5 o k9a f sks^ a d 4ko1a h C 1n o dkogxa o rq o ]tg,n v C0vC[5 d 7q o ou h D

dti5 o k9a f sks^ a d 4ko1a h C 1n o dkogxa o rq o ]tg,n v C c]tsa ^ d 4ko1a h C 1n o 8q ; [5 d 7q o le]a [ [5 d 7q o ou h D

r;dgIq k [+ l k,kfsk[a o mb d dkogdu f 0vC[5 d 7q o ou h w fh D 4h k ;j k [5 d 7q o ou h g du f .oia 4 7k]y 2 = g oa P F dti5 o kxtdv[2v,

7eIh v C0= g vq k [a o mb d dkogdu f .oia 4 7k]y 2 = g oa P mu j 7 a f 8y f ,kou h c ]tlq j C da [ 7n o ,kD

4h k ;j k mj k o[+ , u 0 = h , 6 o mu j w fh 4 k,gvq k 0h k Cgmu C ou h F c8j ; j k de]a C rtpkpk,-vdsk,k.sh F dti5 o k[vd.sh r;dgIq k I6 h D 9q j C 8y f 8+ s h v Cdkola C 7q , lq C

g7ktxt9eg0f0vCmj k oF s^ n x tdv[2v, 7e.sh d kog4u C 7;k,rtpkpk,1j k Clq , gsfzq o .odko0= g vq k s^ a d 4ko1a h C 1n o dkogxa o rq o ]tg,n v C

mu j 7 a f 8y f ,kou h c ]tlq j C da [ 7n o ,kD

(Affidavit of Reasonable Effort to Get Proof of Citizenship)

7k;8u h x tdv[0= h , 6 o .lj - j v Cs;j k C0h k C]5 j , ou h D

County fills out this box.

Case No:

Case Name:

DHCS 0006 (Laotian) (08/07)

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