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

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State of California – Health and Human Services Agency
Department of Health Care Services
‫ﺇﻳﺼﺎﻝ ﺇﺳﺘﻼﻡ ﻭﺛﺎﺋﻖ ﺍﳉﻨﺴﻴﺔ ﺃﻭ ﺍﻟﻬﻮﻳﺔ‬
‫: ﻋﻨﺪ ﺇﺳﺘﻼﻣﻚ ﻟﻮﺛﻴﻘﺔ )ﻭﺛﺎﺋﻖ( ﺍﳉﻨﺴﻴﺔ ﻭ/ﺃﻭ ﺍﻟﻬﻮﻳﺔ ﺍﳋﺎﺻﺔ ﲟﻘﺪﻡ ﺍﻟﻄﻠﺐ ﺃﻭ ﺍﳌﺴﺘﻔﻴﺪ، ﻋﻠﻴﻚ‬DSH/FQHC/‫ﺗﻌﻠﻴﻤﺎﺕ ﻟﻠﻌﺎﻣﻠﲔ ﺑﺎﳌﻘﺎﻃﻌﺔ‬
.‫ﻣﻞﺀ ﻫﺬﺍ ﺍﻟﻨﻤﻮﺫﺝ‬
:‫ﻭﺛﻴﻘﺔ ﺍﳉﻨﺴﻴﺔ ﻭ/ﺃﻭ ﺍﻟﻬﻮﻳﺔ ﺍﳋﺎﺻﺔ ﲟﻘﺪﻡ ﺍﻟﻄﻠﺐ ﺃﻭ ﺍﳌﺴﺘﻔﻴﺪ‬
:‫ﺗﺎﺭﻳﺦ ﺍﳌﻴﻼﺩ‬
‫ﺍﻷﺧﻴﺮ‬
‫ﺍﻷﻭﺳﻂ‬
‫ﺍﻷﻭﻝ‬
:‫ﺍﻟﻌﻨﻮﺍﻥ‬
‫ﺍﻟﺮﻣﺰ ﺍﻟﺒﺮﻳﺪﻱ‬
‫ﺍﻟﻮﻻﻳﺔ‬
‫ﺍﳌﺪﻳﻨﺔ‬
‫ﺍﻟﺸﺎﺭﻉ‬
:‫ﺇﺳﻢ ﺍﻟﻮﺍﻟﺪ ﺇﺫﺍ ﻛﺎﻥ ﻣﻘﺪﻡ ﺍﻟﻄﻠﺐ ﺃﻭ ﺍﳌﺴﺘﻔﻴﺪ ﻃﻔﻞ‬
‫ﺍﻷﺧﻴﺮ‬
‫ﺍﻷﻭﺳﻂ‬
‫ﺍﻷﻭﻝ‬
:‫ ﺍﳋﺎﺹ ﲟﻘﺪﻡ ﺍﻟﻄﻠﺐ ﺃﻭ ﺍﳌﺴﺘﻔﻴﺪ‬BIC/CIN
:‫ﺇﺳﻢ ﻭﺛﻴﻘﺔ ﺍﳉﻨﺴﻴﺔ/ﺍﻟﻬﻮﻳﺔ ﺍﻟﺘﻲ ﺭﺃﻳﺘﻬﺎ‬
:‫ﺇﺳﻢ ﻭﺛﻴﻘﺔ ﺍﳉﻨﺴﻴﺔ/ﺍﻟﻬﻮﻳﺔ ﺍﻟﺘﻲ ﺭﺃﻳﺘﻬﺎ‬
:(‫ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﺘﻲ ﺭﺃﻳﺘﻬﺎ ﻛﺎﻧﺖ )ﺿﻊ ﻋﻼﻣﺔ ﺃﻣﺎﻡ ﺇﺧﺘﻴﺎﺭ ﻭﺍﺣﺪ‬
:(‫ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﺘﻲ ﺭﺃﻳﺘﻬﺎ ﻛﺎﻧﺖ )ﺿﻊ ﻋﻼﻣﺔ ﺃﻣﺎﻡ ﺇﺧﺘﻴﺎﺭ ﻭﺍﺣﺪ‬
(‫ﺃﺻﻠﻴﺔ )ﻟﻴﺴﺖ ﺻﻮﺭﺓ ﺃﻭ ﻧﺴﺨﺔ ﻣﻮﺛﻘﺔ‬
(‫ﺃﺻﻠﻴﺔ )ﻟﻴﺴﺖ ﺻﻮﺭﺓ ﺃﻭ ﻧﺴﺨﺔ ﻣﻮﺛﻘﺔ‬
‫ﻧﺴﺨﺔ ﻣﺼﺪﻗﺔ ﻣﻦ ﺟﻬﺔ ﺍﻹﺻﺪﺍﺭ‬
‫ﻧﺴﺨﺔ ﻣﺼﺪﻗﺔ ﻣﻦ ﺟﻬﺔ ﺍﻹﺻﺪﺍﺭ‬
:(‫ﻫﺬﻩ ﺍﻟﻮﺛﻴﻘﺔ ﺗﻢ ﺇﺳﺘﻼﻣﻬﺎ )ﺿﻊ ﻋﻼﻣﺔ ﺃﻣﺎﻡ ﺇﺧﺘﻴﺎﺭ ﻭﺍﺣﺪ‬
:(‫ﻫﺬﻩ ﺍﻟﻮﺛﻴﻘﺔ ﺗﻢ ﺇﺳﺘﻼﻣﻬﺎ )ﺿﻊ ﻋﻼﻣﺔ ﺃﻣﺎﻡ ﺇﺧﺘﻴﺎﺭ ﻭﺍﺣﺪ‬
‫ﺑﺎﻟﺒﺮﻳﺪ‬
‫ﺑﺎﻟﺒﺮﻳﺪ‬
(‫ﺑﺎﻟﻴﺪ )ﻣﻦ ﻣﻘﺪﻡ ﺍﻟﻄﻠﺐ ﺃﻭ ﺍﳌﺴﺘﻔﻴﺪ‬
(‫ﺑﺎﻟﻴﺪ )ﻣﻦ ﻣﻘﺪﻡ ﺍﻟﻄﻠﺐ ﺃﻭ ﺍﳌﺴﺘﻔﻴﺪ‬
:‫ﺍﻹﺳﻢ‬
:‫ﺍﻹﺳﻢ‬
(‫ﺑﺎﻟﻴﺪ )ﻣﻦ ﻭﺻﻲ، ﳑﺜﻞ ﻣﻔﻮﺽ، ﺃﻭ ﻭﻛﻴﻞ ﺫﻭ ﺻﻠﺔ ﻗﺮﺍﺑﺔ‬
(‫ﺑﺎﻟﻴﺪ )ﻣﻦ ﻭﺻﻲ، ﳑﺜﻞ ﻣﻔﻮﺽ، ﺃﻭ ﻭﻛﻴﻞ ﺫﻭ ﺻﻠﺔ ﻗﺮﺍﺑﺔ‬
(‫)ﺇﺳﻢ ﺍﻟﺸﺨﺺ ﻭﺻ ﹺ ﹺ ﻠﺘﻪ ﲟﻘﺪﻡ ﺍﻟﻄﻠﺐ ﺃﻭ ﺍﳌﺴﺘﻔﻴﺪ‬
(‫)ﺇﺳﻢ ﺍﻟﺸﺨﺺ ﻭﺻ ﹺ ﹺ ﻠﺘﻪ ﲟﻘﺪﻡ ﺍﻟﻄﻠﺐ ﺃﻭ ﺍﳌﺴﺘﻔﻴﺪ‬
‫ﻗﻢ ﺑﻌﻤﻞ ﻧﺴﺨﺔ ﻣﻦ ﻭﺛﻴﻘﺔ ﺍﳉﻨﺴﻴﺔ ﻭ/ﺃﻭ ﺍﻟﻬﻮﻳﺔ ﺍﻟﺘﻲ ﺇﺳﺘﻠﻤﺘﻬﺎ ﻣﻦ ﻣﻘﺪﻡ ﺍﻟﻄﻠﺐ ﺃﻭ ﺍﳌﺴﺘﻔﻴﺪ، ﺃﺭﺟﻊ ﺍﻟﻮﺛﻴﻘﺔ )ﺍﻟﻮﺛﺎﺋﻖ( ﺍﻷﺻﻠﻴﺔ ﳊﺎﻣﻠﻬﺎ ﻭﺃﻋﻄﻪ ﻧﺴﺨﺔ ﻣﻮﻗﻌﺔ‬
‫ﻣﻦ ﺇﻳﺼﺎﻝ ﺍﻹﺳﺘﻼﻡ. ﻋﻨﺪﻣﺎ ﻳﺴﺘﻠﻢ ﻋﺎﻣﻞ ﺍﻷﻫﻠﻴﺔ ﺍﻟﻮﺛﻴﻘﺔ، ﻓﺈﻥ ﻣﻜﺘﺐ ﺍﳋﺪﻣﺎﺕ ﺍﻹﺟﺘﻤﺎﻋﻴﺔ ﻟﻠﻤﻘﺎﻃﻌﺔ ﺳﻴﻘﻮﻡ ﺑﺈﻋﻼﻡ ﻣﻘﺪﻡ ﺍﻟﻄﻠﺐ ﺃﻭ ﺍﳌﺴﺘﻔﻴﺪ ﻋﻦ ﻫﺬﺍ ﺍﻹﻳﺼﺎﻝ‬
‫ ﺇﺭﺳﺎﻝ ﻫﺬﺍ ﺍﻹﻳﺼﺎﻝ ﻭﻧﺴﺦ ﻣﻦ ﺍﻟﻮﺛﻴﻘﺔ )ﺍﻟﻮﺛﺎﺋﻖ( ﺇﻟﻰ ﺍﻟﻘﺴﻢ ﺍﳌﻨﺎﺳﺐ ﻓﻲ‬DSH/FQHC ‫ﺇﺫﺍ ﻛﺎﻧﺖ ﺍﻟﻮﺛﻴﻘﺔ )ﺍﻟﻮﺛﺎﺋﻖ( ﺍﳌﻘﺪﻣﺔ ﻣﻘﺒﻮﻟﺔ. ﻳﺠﺐ ﻋﻠﻰ ﺍﻟﻌﺎﻣﻠﲔ ﺑـ‬
.‫ﻣﻜﺘﺐ ﺍﳋﺪﻣﺎﺕ ﺍﻹﺟﺘﻤﺎﻋﻴﺔ ﻟﻠﻤﻘﺎﻃﻌﺔ‬
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 fills out this box
Case No:
Case Name:
DHCS 0005 (02/08) – Arabic
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