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

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State of California – Health and Human Services Agency
Department of Health Care Services
‫ﺷﻬﺎدة ﺧﻄ ﻴ ّﺔ ﻹﺛﺒﺎت ﻣﺤﺎوﻟﺔ اﳊﺼﻮل ﻋﻠﻰ وﺛﻴﻘﺔ اﺛﺒﺎت اﳉﻨﺴﻴﺔ‬
‫اﻣﻸ اﻟﺘﺎﻟﻲ‬
(‫)ﺑﺄﺣﺮف ﻛﺒﻴﺮة‬
:(‫)اﻷﺳﻢ‬
‫اﺣﺎول اﳊﺼﻮل ﻋﻠﻰ وﺛﻴﻘﺔ اﺛﺒﺎت اﳉﻨﺴﻴﺔ ﻟـ‬
‫اﻷﺧﻴﺮ‬
‫اﻟﻮﺳﻂ‬
‫اﻷول‬
.‫ﻟﻘﺪ ﺣﺎوﻟﺖ اﳊﺼﻮل ﻋﻠﻰ وﺛﻴﻘﺔ اﺛﺒﺎت اﳉﻨﺴﻴﺔ ﻣﻦ اﻷﺷﺨﺎص أواﳌﺆﺳﺴﺎت اﳌﺬﻛﻮرﻳﻦ ادﻧﺎه‬
(.‫)اﻛﺘﺐ ﺗﻮارﻳﺦ اﻹﺗﺼﺎل واﳌﺪة اﳌﻄﻠﻮﺑﺔ ﻟﻠﺤﺼﻮل ﻋﻠﻰ اﺛﺒﺎت اﳉﻨﺴﻴﺔ‬
‫اﻟﺘﺎرﻳﺦ اﻟﺬي ﺳﻴﺘﻢ اﻟﺮد ﻓﻴﻪ‬
‫ﺗﺎرﻳﺦ اﳌﺮاﺟﻌﺔ‬
‫اﻟﻮﺛﺎق اﳌﻄﻠﻮﺑﺔ‬
‫اﺳﻢ اﻟﺸﺨﺺ أو اﳌﺆﺳﺴﺔ اﻟﺘﻲ ﻗﻤﺖ ﲟﺮاﺟﻌﺘﻬﺎ‬
:‫وﺿﺢ ادﻧﺎه اي ﻣﻌﻠﻮﻣﺎت اﺧﺮى ﻋﻦ ﻣﺤﺎوﻟﺘﻚ ﻓﻲ اﳊﺼﻮل ﻋﻠﻰ وﺛﻴﻘﺔ اﺛﺒﺎت اﳉﻨﺴﻴﺔ‬
(‫اﺳﻤﻚ )ﺑﺄﺣﺮف ﻛﺒﻴﺮة‬
‫اﻟﺘﺎرﻳﺦ‬
‫ﺗﻮﻗﻴﻌﻚ‬
.‫اذا ﻛﻨﺖ ﺑﺤﺎﺟﺔ ﻟﻠﻤﺴﺎﻋﺪة ﻣﻊ ﻫﺬا اﻟﻨﻤﻮذج، اﻟﺮﺟﺎء اﻻﺗﺼﺎل ﲟﻜﺘﺐ اﳋﺪﻣﺎت اﻷﺟﺘﻤﺎﻋﻴﺔ اﶈﻠﻲ‬
‫ﲤﻸ اﳌﻘﺎﻃﻌﺔ اﳌﺮﺑﻊ اﻟﺘﺎﻟﻲ‬
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) – Arabic
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