Form Dhcs 0003 - California Affidavit Of Reasonable Effort To Get Proof Of Citizenship (Armenian) - Health And Human Services Agency

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State of California – Health and Human Services Agency
Department of Health Care Services
ø³Õ³ù³óÇáõÃÛ³Ý »õ ÇÝùÝáõÃÛ³Ý Ù³ëÇÝ ³å³óáõÛó Ó»éù μ»ñ»Éáõ ѳٳñ
ÁݹáõÝ»ÉÇ ç³Ýù óáõó³μ»ñ»Éáõ ѳëï³ï³·Çñ
Èñ³óñ»ù Ý»ñù»õáõÙ
(ïå³·Çñ)
ºë ÷áñÓáõÙ »Ù ù³Õ³ù³óÇáõÃÛ³Ý Ù³ëÇÝ ³å³óáõÛó Ó»éù μ»ñ»É Ñ»ï»õÛ³É ³ÝÓÇ Ñ³Ù³ñ
.
(³ÝáõÝÁ)
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²½·³ÝáõÝÁ
ºë ÷áñÓ»É »Ù ù³Õ³ù³óÇáõÃÛ³Ý Ù³ëÇÝ ³å³óáõÛó Ó»éù μ»ñ»É Ý»ñù»õáõÙ Ãí³ñÏíáÕ ³ÝÓ³ÝóÇó ϳÙ
·áñͳϳÉáõÃÛáõÝÝ»ñÇó:
(Üß»ó»ù ݳ»õ ϳåí»Éáõ ³Ùë³Ãí»ñÁ »õ ÇÝãù³Ý Å³Ù³Ý³Ï Ïå³Ñ³ÝçíÇ ù³Õ³ù³óÇáõùÛ³Ý Ù³ëÇÝ ³å³óáõÛóÁ
ëï³Ý³Éáõ ѳٳñ):
²ÝÓÇ Ï³Ù ·áñͳϳÉáõÃÛ³Ý
Ëݹñí³Í
ϳåí»Éáõ
²Ùë³ÃÇíÁ, »ñμ
³ÝáõÝÁ, áõÙ Ñ»ï ϳåí»É »Ù
÷³ëï³ÃáõÕÃÁ
³Ùë³ÃÇíÁ
Ïå³ï³ë˳ݻÝ
Ü»ñù»õáõÙ ïí»ù áñ»õ¿ ³ÛÉ ï»Õ»ÏáõÃÛáõÝ` ù³Õ³ù³óÇáõÃÛ³Ý Ù³ëÇÝ ³å³óáõÛó Ó»éù μ»ñ»Éáõ ѳٳñ Ó»ñ
·áñͳ¹ñ³Í ç³ÝùÇ Ù³ëÇÝ.
Ò»ñ ³ÝáõÝÁ (ïå³·Çñ)
Ò»ñ ëïáñ³·ñáõÃÛáõÝÁ
²Ùë³ÃÇí
ºÃ» ³Ûë Ó»õÁ Éñ³óÝ»Éáõ ѳٳñ û·ÝáõÃÛ³Ý Ï³ñÇù áõݻݳù, ½³Ý·³Ñ³ñ»ù Ó»ñ ï»Õ³Ï³Ý êáódzɳϳÝ
³å³ÑáíáõÃÛ³Ý Í³é³ÛáõÃÛáõÝÝ»ñÇ ·ñ³ë»ÝÛ³ÏÇÝ:
ø³áõÝÃÇÝ ÏÉñ³óÝÇ Ý»ñù»õÇ ïáõ÷ÇÏÁ
County fills out this box
Case No:
Case Name:
If this Affidavit is taken on the phone, fill out below:
County worker’s name and signature
Date
DHCS 0003 (06/07) – Armenian
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