Form Dhcs 0003 - California Affidavit Of Reasonable Effort To Get Proof Of Citizenship (Chinese) - Health And Human Services Agency
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1State of California – Health and Human Services Agency
Department of Health Care Services
盡力尋找公民身份證明的書面陳述
請填寫以下各項
（正楷書寫）
我正在為此人尋找公民身份的證明（
姓名） ：
名
中間名
姓
我試圖從以下所列的人士或機構索取公民身份的證明。
（並請說明聯絡的日期及索取公民身份證明所需的時間。）
聯絡人姓名或機構名稱
索取文件
聯絡日期
答覆日期
在此說明有關您努力尋找公民身份證明的任何其他情況：
您的姓名（正楷書寫）
您的簽名
日期
如果您填寫此表需要幫助，請打電話給您當地的社會服務辦公室。
以下欄目由縣裡填寫
County fi lls out this box
Case No:
Case Name:
If this Affi davit is taken on the phone, fi ll out below:
County worker’s name and signature
Date
DHCS 0003 (06/07) – Chinese
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