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State of California – Health and Human Services Agency

Department of Health Care Services

Bieâ n Nhaä n cho Vaê n Kieä n Quoá c Tòch hoaë c Caê n Cöôù c

Höôù n g daã n cho Nhaâ n Vieâ n Quaä n /DSH/FQHC: Khi nhaä n ñöôï c (caù c ) vaê n kieä n quoá c tòch vaø / hoaë c caê n cöôù c

cho moä t ngöôø i noä p ñôn hoaë c höôû n g phuù c lôï i , quyù vò phaû i ñieà n maã u naø y .

Vaê n kieä n Quoá c Tòch/Caê n Cöôù c cho Ngöôø i Noä p Ñôn hoaë c Höôû n g Phuù c Lôï i :

Ngaø y sinh:

Teâ n

Teâ n Loù t

Hoï

Ñòa chæ:

Ñöôø n g

Thaø n h Phoá

Tieå u Bang

Soá Zip

Teâ n cha meï neá u Ngöôø i Noä p Ñôn hoaë c

Höôû n g Phuù c Lôï i laø moä t treû em:

Teâ n

Teâ n Loù t

Hoï

BIC/CIN cuû a Ngöôø i Noä p Ñôn hoaë c Höôû n g Phuù c Lôï i :

Teâ n vaê n kieä n quoá c tòch/caê n cöôù c quyù vò thaá y :

Vaê n kieä n quyù vò thaá y laø (choï n moä t ):

Moä t baû n chính (khoâ n g phaû i baû n sao hoaë c baû n

chöù n g thöï c )

Moä t baû n sao coù chöù n g thöï c töø cô quan caá p phaù t

Vaê n kieä n naø y nhaä n ñöôï c (choï n moä t ):

Qua böu ñieä n

Taä n tay (töø ngöôø i noä p ñôn hoaë c höôû n g phuù c lôï i )

Teâ n :

Taä n tay (töø moä t giaù m hoä , ñaï i dieä n coù pheù p , hoaë c

thaâ n nhaâ n chaê m soù c )

(Teâ n vaø quan heä ñoá i vôù i ngöôø i noä p ñôn hoaë c

höôû n g phuù c lôï i )

Sao chuï p moä t baû n vaê n kieä n quoá c tòch vaø / hoaë c caê n cöôù c nhaä n ñöôï c töø ngöôø i noä p ñôn hoaë c höôû n g phuù c

lôï i , göû i traû (caù c ) vaê n kieä n goá c laï i cho ngöôø i chuû vaø cung caá p moä t baû n bieâ n nhaä n coù chöõ kyù cho ngöôø i chuû .

Sau khi nhaâ n vieâ n xeù t hoà sô nhaä n ñöôï c vaê n kieä n , vaê n phoø n g dòch vuï xaõ hoä i quaä n seõ thoâ n g baù o cho ngöôø i

noä p ñôn hoaë c höôû n g phuù c lôï i bieá t vieä c naø y neá u (caù c ) vaê n kieä n ñaõ noä p ñöôï c chaá p thuaä n . Nhaâ n vieâ n DSH/

FQHC phaû i göû i bieâ n nhaä n naø y vaø phoù baû n (caù c ) vaê n kieä n ñeá n vaê n phoø n g dòch vuï xaõ hoä i quaä n thích hôï p .

County/DSH/FQHC Staff reads and signs below.

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 County/DSH/FQHC Staff

Name of County/DSH/FQHC Staff

(print):

First

Middle

Last

Information:

Name of agency

County

Telephone number

E-mail

County ﬁ lls out this box

Case No:

Case Name:

DHCS 0005 (02/08) – Vietnamese

Page 1 of 1

Form Dhcs 0005 - California Receipt Of Citizenship Or Identity Documents (Vietnamese) - Health And Human Services Agency

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