Looking for a California Health And Human Services Agency Forms And Templates? Download it for free!

State of California – Health and Human Services Agency

Department of Health Care Services

،‫ﺳﺎل ﻛﻪ اﻇﻬﺎر ﻧﺎﻣﻪ ﺳﻴﺘﻲ زن ﺷﻴﭙﻲ اراﺋﻪ ﻧﺪاده‬

‫ﺑﺮاي ﻛﻮدك زﻳﺮ‬

‫❖ ﮔﻮاﻫﻲ دارا ﺑﻮدن ﺧﻮن ﺳﺮﺧﭙﻮﺳﺘﻲ ﻳﺎ ﺳﺎﻳﺮ ﺳﻮاﺑﻖ ﻗﺒﻴﻠﻪ اي ﻣﺮﺑﻮط‬

:‫ﺷﻤﺎ ﻣﻲ ﺗﻮاﻧﻴﺪ اﻳﻦ ﻣﺪارك را ﺗﺴﻠﻴﻢ ﻛﻨﻴﺪ‬

‫ﺑﻪ ﺳﺮﺧﭙﻮﺳﺘﺎن اﻳﺎﻻت ﻣﺘﺤﺪه/ ﺑﻮﻣﻴﺎن آﻻﺳﻜﺎ‬

‫❖ ﻛﺎرت ﺷﻨﺎﺳﺎﺋﻲ ﮔﺎرد ﺳﺎﺣﻠﻲ اﻳﺎﻻت ﻣﺘﺤﺪه ﻣﻮﺳﻮم ﺑﻪ‬

Merchant

٬‫❖ ﻳﻚ اﻇﻬﺎر ﻧﺎﻣﻪ ﻣﺮﺑﻮط ﺑﻪ ﻫﻮﻳﺖ ﻛﻮدك ﻛﻪ ﺑﻪ اﻣﻀﺎي واﻟﺪ‬

Mariner

‫ﺳﺮﭘﺮﺳﺖ٬ ﻳﺎ ﺧﻮﻳﺸﺎوﻧﺪ ﻛﻮدك ﺷﺨﺺ رﺳﻴﺪه و ﺗﺎرﻳﺦ و ﻣﺤﻞ ﺗﻮﻟﺪ را‬

‫ﻧﺸﺎن ﻣﻴﺪﻫﺪ‬

٬‫❖ ﺳﻪ ﻣﺪرك ﺗﺄﻳﻴﺪ ﻫﻮﻳﺖ ﻳﺎ ﺑﻴﺸﺘﺮ از ﻗﺒﻴﻞ ﻛﺎرت ﻫﺎي ﺷﻨﺎﺳﺎﺋﻲ اﺳﺘﺨﺪاﻣﻲ‬

‫دﺑﻴﺮﺳﺘﺎن ﻳﺎ ﻣﺪارك داﻧﺸﮕﺎﻫﻲ٬ ﺳﻨﺪ ازدواج٬ ﺣﻜﻢ ﻃﻼق ﻳﺎ ﺳﻨﺪ‬

‫❖ ﺗﻘﺎﺿﺎﻧﺎﻣﻪ‬

Healthy Families/

‫ﻳﺎ ﺗﻘﺎﺿﺎﻧﺎﻣﻪ ﻣﺸﺘﺮك‬

Medi-Cal

‫ﻣﺎﻟﻜﻴﺖ/ﻗﺒﺎﻟﻪ زﻣﲔ‬

Medi-Cal

‫ﻛﻪ ﺗﺎرﻳﺦ و ﻣﺤﻞ ﺗﻮﻟﺪ ﻛﻮدك را ﻧﺸﺎن ﻣﻲ دﻫﺪ و ﺗﻮﺳﻂ‬

.‫واﻟﺪﻳﻦ٬ ﺳﺮﭘﺮﺳﺖ٬ ﻳﺎ ﺧﻮﻳﺸﺎوﻧﺪ ﻣﺮاﻗﺐ ﻛﻮدك اﻣﻀﺎء ﺷﺪه اﺳﺖ‬

‫❖ ﺳﻮاﺑﻖ ﻣﺮﺑﻮط ﺑﻪ ﻛﻠﻴﻨﻴﻚ٬ ﭘﺰﺷﻚ٬ ﻳﺎ ﺑﻴﻤﺎرﺳﺘﺎن ﺑﺮاي اﺷﺨﺎص ﻛﻤﺘﺮ از‬

‫ﺳﺎل‬

‫ﺳﺎل ﭼﻨﺎﻧﭽﻪ اوراق ﺷﻨﺎﺳﺎﺋﻲ ﻣﺪرﺳﻪ ﻳﺎ‬

‫ﺑﺮاي اﺷﺨﺎص ﻛﻤﺘﺮ از‬

‫❖ ﺳﻮاﺑﻖ ﻣﺪرﺳﻪ٬ ﻛﻮدﻛﺴﺘﺎن ﻳﺎ ﻣﻬﺪ ﻛﻮدك٬ از ﺟﻤﻠﻪ ﻛﺎرﻧﺎﻣﻪ ﻫﺎ ﺑﺮاي‬

‫ﮔﻮاﻫﻴﻨﺎﻣﻪ راﻧﻨﺪﮔﻲ ﻣﻮﺟﻮد ﻧﺒﺎﺷﺪ٬ اﻇﻬﺎرﻧﺎﻣﻪ ﻫﻮﻳﺖ ﻛﻮدك ﻛﻪ ﺑﻪ اﻣﻀﺎي‬

‫ﺳﺎل. ﻛﺎﻧﺘﻲ ﺗﺄﻳﻴﺪﻳﻪ ﺻﺤﺖ ﻣﺪارك ﻓﻮق را از ﻣﺪرﺳﻪ‬

‫اﺷﺨﺎص زﻳﺮ‬

‫واﻟﺪ٬ ﺳﺮﭘﺮﺳﺖ ﻳﺎ ﺧﻮﻳﺸﺎوﻧﺪ ﻣﺮاﻗﺐ ﻛﻮدك رﺳﻴﺪه ﺑﺎﺷﺪ ﻣﻲ ﺗﻮاﻧﺪ ﻣﻮرد‬

.‫ﺧﻮاﻫﺪ ﮔﺮﻓﺖ‬

.‫اﺳﺘﻔﺎده ﻗﺮار ﮔﻴﺮد‬

‫❖ ﺑﺮاي ﻣﻌﻠﻮﻟﻴﻨﻲ ﻛﻪ در ﻣﺤﻠﻬﺎي ﻣﺮاﻗﺒﺘﻲ ﻣﺴﻜﻮﻧﻲ زﻧﺪﮔﻲ ﻣﻲ ﻛﻨﻨﺪ٬ ﻳﻚ‬

‫ﺗﻮﺟﻪ: ﻣﺪارك ﺷﻨﺎﺳﺎﺋﻲ ﻣﻨﻘﻀﻲ ﺷﺪه ﺑﻌﻨﻮان ﺳﻨﺪ ﻫﻮﻳﺖ داراي اﻋﺘﺒﺎر‬

‫اﻇﻬﺎر ﻧﺎﻣﻪ ﻛﻪ ﺑﻪ اﻣﻀﺎي رﺋﻴﺲ ﻳﺎ ﻣﺪﻳﺮ ﻣﺤﻞ رﺳﻴﺪه اﺳﺖ‬

.‫ﻫﺴﺘﻨﺪ‬

DHCS 0007 (12/07) – Farsi

Page 2 of 2

Form Dhcs 0007 - California Acceptable Citizenship And Identity Documents (Farsi) - Health And Human Services Agency Page 2