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

State of California – Health and Human Services Agency

Department of Health Care Services

Baû n Khai Chöù n g Theä veà Noã Löï c Hôï p Lyù ñeå Tìm Baè n g Chöù n g veà Quoá c Tòch

Ñieà n phaà n döôù i ñaâ y

(vieá t chöõ in)

Toâ i ñang tìm baè n g chöù n g veà quoá c tòch cho

(teâ n ):

Teâ n

Teâ n Loù t

Hoï

Toâ i ñaõ tìm caù c h laá y baè n g chöù n g veà quoá c tòch töø nhöõ n g ngöôø i hoaë c cô quan lieä t keâ döôù i ñaâ y .

(Lieä t keâ caû ngaø y thaù n g lieâ n laï c vaø thôø i gian caà n bao laâ u ñeå laá y ñöôï c baè n g chöù n g veà quoá c tòch.)

Teâ n cuû a ngöôø i hoaë c

Giaá y Tôø

Ngaø y

Ngaø y hoï seõ

cô quan ñaõ lieâ n laï c

yeâ u caà u

lieâ n laï c

traû lôø i

Giaû i thích döôù i ñaâ y baá t cöù chi tieá t naø o veà noã löï c tìm kieá m baè n g chöù n g quoá c tòch cuû a quyù vò:

Hoï teâ n quyù vò (vieá t chöõ in)

Chöõ kyù cuû a quyù vò

Ngaø y

Neá u quyù vò caà n giuù p ñôõ veà maã u ñôn naø y , xin goï i cho vaê n phoø n g dòch vuï xaõ hoä i ñòa phöông cuû a quyù vò.

Quaä n ñieà n khung döôù i ñaâ y

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) – Vietnamese

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