Form Dhcs 0004 - California Request For California Birth Record (Farsi) - Health And Human Services Agency

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State of California – Health and Human Services Agency
Department of Health Care Services
‫درﺧﻮاﺳﺖ ﺑﺮا ﻣﺪرك ﺳﺎﺑﻘﻪ ﺗﻮﻟﺪ در ﺎﻟ ﻔﺮﻧ ﺎ‬
!‫ ﻣﻲ ﺗﻮاﻧﺪ ﺑﺮاي اﻓﺮادي ﻛﻪ در ﻛﺎﻟﻴﻔﺮﻧﻴﺎ ﺑﺪﻧﻴﺎ آﻣﺪه اﻧﺪ ﺗﻘﺎﺿﺎي ﻣﺪرك ﺳﺎﺑﻘﻪ ﺗﻮﻟﺪ ﻛﻦ — ﺑﻪ ﻃﻮر راﻳﮕﺎن‬Medi- Cal ‫ﻣﺪ ﻞ‬
:‫ﺑﺪ ﻦ ﺻﻮرت‬
:‫ﺗﺎر ﺦ اﻣﺮوز‬
:‫ﺳﺎل‬
:‫روز‬
:‫ﻣﺎه‬
‫• ا ﻦ ﻓﺮم را ﭘﺮ ﻨ ﺪ. ﻠﻤﺎت‬
:‫ﻨﺪ‬
: ‫ﻧﺎم ﺧﺎﻧﻮادﮔ‬
: ‫ﻧﺎم ﻣ ﺎﻧ‬
:‫ﻧﺎم‬
‫ﻪ ا ﻦ ﻓﺮم را ﭘﺮ ﻣ‬
‫ﻧﺎم ﺷﺨﺼ‬
‫ﻠﻤﺎت را ﺗﺎ ﭗ ﻨ ﺪ ﺎ‬
‫ﺧﻮاﻧﺎ ﺑﻨﻮ ﺴ ﺪ. ﺷﻤﺎ ﻣ‬
‫ﺗﻮاﻧ ﺪاﻃﻼﻋﺎت ﻻزم ﺑﺮا‬
‫ﺳﺎﺑﻘﻪ ﺗﻮﻟﺪ ﭼﻪ ﺴ را ﻣ ﺧﻮاﻫ ﺪ؟‬
:‫ﻧﺎم ﺷﺨﺺ رو ﺳﻨﺪ ﻫﻮ ﺖ‬
‫ﺗ ﻤ ﻞ ﺮدن ا ﻦ ﻓﺮم را از‬
: ‫ﻧﺎم ﺧﺎﻧﻮادﮔ‬
: ‫ﻧﺎم ﻣ ﺎﻧ‬
:‫ﻧﺎم‬
.‫ﭙ ﺳﻨﺪ ﺗﻮﻟﺪ ﺑﺪﺳﺖ آور ﺪ‬
‫اﮔﺮ ا ﻦ ﺷﺨﺺ ﺑﻪ ﻓﺮزﻧﺪ ﺧﻮاﻧﺪﮔ ﭘﺬ ﺮﻓﺘﻪ ﺷﺪه، ﻧﺎم‬
‫• ﻓﺮم ﺗ ﻤ ﻞ ﺷﺪه را ﺑﻪ اداره‬
:‫ﺟﺪ ﺪ او را ﺑﻨﻮ ﺴ ﺪ‬
: ‫ﻧﺎم ﺧﺎﻧﻮادﮔ‬
: ‫ﻧﺎم ﻣ ﺎﻧ‬
:‫ﻧﺎم‬
‫ﺳﻮﺳ ﺎل ﺳ ﻮرﺗ ﻣﺤﻞ‬
o
o
:‫ﺟﻨﺴ ﺖ‬
.‫ﺑ ﺎور ﺪ ﺎ ﺑﺮا آن ﭘﺴﺖ ﻨ ﺪ‬
‫زن‬
‫ﻣﺮد‬
‫• اﮔﺮ ﺑﺮا ﭘﺮ ﺮدن ا ﻦ ﻓﺮم‬
:‫ﺗﺎر ﺦ ﺗﻮﻟﺪ‬
:‫ﺳﺎل‬
:‫روز‬
:‫ﻣﺎه‬
‫ﻣﺸ ﻠ دار ﺪ ﺑﺎ اداره ﺧﺪﻣﺎت‬
:‫ﺷﻬﺮ و ﺎﻧﺘ ﻣﺤﻞ ﺗﻮﻟﺪ‬
:‫ﺎﻟ ﻔﺮﻧ ﺎ‬
:‫ﺷﻬﺮ‬
‫ﺎﻧﺘ‬
‫اﺟﺘﻤﺎﻋ ﻣﺤﻞ ﺧﻮد ﲤﺎس‬
.‫ﺑﮕ ﺮ ﺪ‬
:‫ﻧﺎم ﺧﺎﻧﻮادﮔ ﻣﺎدر ﻗﺒﻞ از ازدواج‬
: ‫ﻧﺎم ﺧﺎﻧﻮادﮔ‬
: ‫ﻧﺎم ﻣ ﺎﻧ‬
:‫ﻧﺎم‬
:‫ﻧﺎم ﭘﺪر‬
‫ﳑ ﻦ اﺳﺖ ﻣﺎ ﻧﺘﻮاﻧ ﻢ ﺳﺎﺑﻘﻪ‬
: ‫ﻧﺎم ﺧﺎﻧﻮادﮔ‬
: ‫ﻧﺎم ﻣ ﺎﻧ‬
:‫ﻧﺎم‬
‫ﺗﻮﻟﺪ را ﻪ ﺷﻤﺎ ﺧﻮاﻫﺎن آن‬
) ‫ﺷﻤﺎره ﮔﻮاﻫ ﺗﻮﻟﺪ‬
:(‫اﮔﺮ ﻣ داﻧ ﺪ‬
‫ﻫﺴﺘ ﺪ ﺑﺪﺳﺖ آور ﻢ. اﮔﺮ ﭼﻨ ﻦ‬
‫ﭼ ﺰ ﭘ ﺶ آ ﺪ، ﺷﻤﺎ ﺑﺎ ﺪ ﻣﺪار‬
‫د ﮕﺮ را ﺑﻌﻨﻮان ﺳﻨﺪ ﺳ ﺘ زن‬
‫ﻪ ﺳﺎﺑﻘﻪ‬
‫ﻧﺎم ﺷﺨﺺ ﺑﻌﺪ‬
.‫ﺷ ﭙ اراﺋﻪ دﻫ ﺪ‬
:‫ﺗﻮﻟﺪ او را ﻣ ﺧﻮاﻫ ﺪ‬
: ‫ﻧﺎم ﺧﺎﻧﻮادﮔ‬
: ‫ﻧﺎم ﻣ ﺎﻧ‬
:‫ﻧﺎم‬
‫اﮔﺮ ا ﻦ ﺷﺨﺺ ﺑﻪ ﻓﺮزﻧﺪ ﺧﻮاﻧﺪﮔ ﭘﺬ ﺮﻓﺘﻪ ﺷﺪه، ﻧﺎم‬
‫ﻪ‬
‫ﻣﺎ اﮔﺮ ﺑﻪ ﺳﺎﺑﻘﻪ ﺗﻮﻟﺪ‬
:‫ﺟﺪ ﺪ او را ﺑﻨﻮ ﺴ ﺪ‬
‫ﺷﻤﺎ ﺧﻮاﺳﺘﺎر آن ﻫﺴﺘ ﺪ دﺳﺖ‬
: ‫ﻧﺎم ﺧﺎﻧﻮادﮔ‬
: ‫ﻧﺎم ﻣ ﺎﻧ‬
:‫ﻧﺎم‬
‫ﺎﺑ ﻢ، ﻫﻨﻮز ﻫﻢ ﺑﺎ ﺪ ﺳﻨﺪ ﻫﻮ ﺖ‬
o
o
:‫ﺟﻨﺴ ﺖ‬
‫زن‬
‫ﻣﺮد‬
.‫را اراﺋﻪ دﻫ ﺪ‬
:‫ﺗﺎر ﺦ ﺗﻮﻟﺪ‬
:‫ﺳﺎل‬
:‫روز‬
:‫ﻣﺎه‬
‫ﺎﻧﺘ ﺑﻪ‬
‫دﻓﺘﺮ ﺧﺪﻣﺎت اﺟﺘﻤﺎﻋ‬
‫اﻃﻼﻋﺎت درﺧﻮاﺳﺖ ﺷﺪه ﺑﺮا‬
:‫ﺷﻬﺮ و ﺎﻧﺘ ﻣﺤﻞ ﺗﻮﻟﺪ‬
:‫ﺎﻟ ﻔﺮﻧ ﺎ‬
:‫ﺷﻬﺮ‬
‫ﺎﻧﺘ‬
‫ﺟﺴﺘﺠﻮ در ﺳﻮاﺑﻖ ﺗﻮﻟﺪ در ﺎﻟ ﻔﺮﻧ ﺎ‬
‫و ﺑﻪ ﻣﻨﻈﻮر ﺛﺎﺑﺖ ﺮدن ﺳ ﺘ زن‬
:‫ﻧﺎم ﺧﺎﻧﻮادﮔ ﻣﺎدر ﻗﺒﻞ از ازدواج‬
: ‫ﻧﺎم ﺧﺎﻧﻮادﮔ‬
: ‫ﻧﺎم ﻣ ﺎﻧ‬
:‫ﻧﺎم‬
‫ﺷ ﭙ ﻧ ﺎز دارد. ﺷﻤﺎ ﻣﺠﺒﻮر ﻧ ﺴﺘ ﺪ‬
‫ﻪ ا ﻦ اﻃﻼﻋﺎت را اراﺋﻪ دﻫ ﺪ. اﻣﺎ‬
:‫ﻧﺎم ﭘﺪر‬
: ‫ﻧﺎم ﺧﺎﻧﻮادﮔ‬
: ‫ﻧﺎم ﻣ ﺎﻧ‬
:‫ﻧﺎم‬
‫اﮔﺮ ﭼﻨ ﻦ ﻧ ﻨ ﺪ، ﳑ ﻦ اﺳﺖ ﺎﻧﺘ‬
.‫ﻧﺘﻮاﻧﺪ ﺳﺎﺑﻘﻪ ﺗﻮﻟﺪ را ﺑ ﺎﺑﺪ‬
) ‫ﺷﻤﺎره ﮔﻮاﻫ ﺗﻮﻟﺪ‬
:(‫اﮔﺮ ﻣ داﻧ ﺪ‬
.‫اﮔﺮ ﺑﻪ ﺑ ﺶ از دو ﺳﺎﺑﻘﻪ ﺗﻮﻟﺪ ﻧ ﺎز دار ﺪ، ﻓﺮم د ﮕﺮ را ﭘﺮ ﻨ ﺪ‬
DHCS 0004 (06/07) – Farsi
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