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

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State of California – Health and Human Services Agency
Department of Health Care Services
Daim Receipt Qhia Tias Tau Txais Cov Puavpheej Uas Qhia Tias Yog Neeg
Amelikas lossis Yog Leejtwg Tiag Lawm
Kev qhia rau cov neeg ua haujlwm hauv County/DSH/FQHC: Thaum koj tau txais cov puavpheej uas qhia tias yog
neeg Amelikas thiab/lossis yog leejtwg tiag lawm rau ib tus neeg tabtom tuaj thov lossis tau txais kev pabcuam, koj
yuavtsum tau ua daim ntawv no.
Cov Puavpheej Uas Qhia Tias Yog Neeg Amelikas/Yog Leejtwg Tiag rau tus neeg tabtom Tuaj Thov lossis Tau Txais:
Hnub Yug:
Npe
Npe Nrab
Xeem
Chaw nyob:
Txoj kev
Nroog
Xeev
Zip Code
Niamtxiv npe yog tias tus neeg tabtom Tuaj Thov
lossis Tau Txais kev pabcuam yog ib tus menyuam yaus:
Npe
Npe Nrab
Xeem
Tus neeg tabtom Tuaj Thov lossis Tau Txais tus lej BIC/CIN:
Lub npe ntawm daim puavpheej uas qhia tias yog neeg
Lub npe ntawm daim puavpheej uas qhia tias yog neeg
Amelikas/yog leejtwg tiag uas koj pom:
Amelikas/yog leejtwg tiag uas koj pom:
Daim puavpheej uas koj tau pom yog (khij ib qhov):
Daim puavpheej uas koj tau pom yog (khij ib qhov):
Yog daim tseem (tsis yog daim luam los lossis muaj
Yog daim tseem (tsis yog daim luam los lossis muaj
neeg lees tias yog daim tseem)
neeg lees tias yog daim tseem)
Yog ib daim luam uas lub koomhaum uas ua daim
Yog ib daim luam uas lub koomhaum uas ua daim
ntawv ntawd nias lawv lub cim rau tias yog daim tseem
ntawv ntawd nias lawv lub cim rau tias yog daim tseem
Tau txais daim ntawv no los ntawm (khij ib qhov):
Tau txais daim ntawv no los ntawm (khij ib qhov):
Xa tuaj hauv ntawv
Xa tuaj hauv ntawv
Nqa tuaj (los ntawm tus neeg tabtom tuaj thov lossis
Nqa tuaj (los ntawm tus neeg tabtom tuaj thov lossis
tus tau txais) Npe:
tus tau txais) Npe:
Nqa tuaj (los ntawm tus neeg saib xyuas, tus neeg
Nqa tuaj (los ntawm tus neeg saib xyuas, tus neeg
sawvcev, lossis tus neeg nrog tu)
sawvcev, lossis tus neeg nrog tu)
(Nws npe thiab nws txheeb rau tus tabtom tuaj thov
(Nws npe thiab nws txheeb rau tus tabtom tuaj thov
lossis tus neeg tau txais ntawd licas)
lossis tus neeg tau txais ntawd licas)
Luam daim puavpheej uas qhia tias yog neeg Amelikas thiab/lossis yog leejtwg tiag uas koj tau txais los ntawm tus neeg
tabtom tuaj thov lossis tau txais, muab daim tseem puavpheej rov rau tus neeg uas nqa tuaj thiab ua, suam npe thiab
muab daim receipt uas qhia tias tau txais lawm rau tus neeg uas nqa daim puavpheej tuaj. Thaum tus neeg tuav ntaub
ntawv tau txais daim puavpheej lawm, lub county social services offi ce yuav sau ntawv tuaj qhia rau tus neeg tabtom tuaj
thov lossis tus neeg tau txais tias lawv puas kam txais cov ntaub ntawv ntawd ua puavpheej. Cov neeg ua haujlwm hauv
DSH/FQHC yuavtsum tau xa daim receipt no thiab cov ntaub ntawv puavpheej uas lawv luam tau mus rau lub county
social services offi ce uas tuav nws tej ntaub ntawv.
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) – Hmong
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