Form Dhcs 0001 - California U.s. Citizens And Nationals Applying For Medi-Cal Must Show Proof Of Citizenship And Identity (Arabic) - Health And Human Services Agency Page 3
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4State of California – Health and Human Services Agency
وﺛﺎﺋق اﺛﺑﺎت اﻟﺟﻧﺳﻳﺔ واﻟﺷﺧﺻﻳﺔ اﻟﻣﻘﺑوﻟﺔ
Department of Health Care Services
اﺳﻬل طرﻳﻘﺔ ﻟﻠﻣواطﻧﻳن اﻻﻣرﻳﻛﻳﻳن أو اﻟذﻳن ﻳﺣﻣﻠون اﻟﺟﻧﺳﻳﺔ اﻷﻣرﻳﻛﻳﺔ ﻟﺗﻘدﻳم وﺛﻴﻘﺘﻲ دﻟﻳل اﺛﺑﺎت اﻟﺟﻧﺳﻳﺔ واﻟﺷﺧﺻﻳﺔ ﻫﻲ
:ﺗﻘدﻳم واﺣدة ﻣن ﻫذه اﻟوﺛﺎﺋق
أو
ﻳﻣﻛن ﻗﺑول اﻟﻣﻧﺗﻬﻳﺔ ﻣدﺗﻬم
ﺟواز ﺳﻔر اﻣرﻳﻛﻲ ﻏﻳر ﻣﺷروط
،(
)
—
أو
أو
وﺛﻳﻘﺔ اﻟﺗﺟﻧﻳس
،(N-570
N-550)
—
أو
وﺛﻳﻘﺔ ﺟﻧﺳﻳﺔ اﻣرﻳﻛﻳﺔ
(N-561
N-560)
—
– – أو
....اذا ﻟﻢ ﺗﻜﻦ ﲤﻠﻚ واﺣﺪة ﻣﻦ اﻟﻮﺛﺎﺋﻖ اﻋﻼه، ﻗﺪم
:واﺣدة ﻣن وﺛﺎﺋق اﺛﺑﺎت اﻟﺟﻧﺳﻳﺔ ﻣن اﻟﻧﻘﺎط اﻟﺗﺎﻟﻳﺔ
❖ ﺳﺟل ﺗﻌداد ﺳﻛﺎﻧﻲ ﻓﻳدﻳراﻟﻲ او ﻣن اﻟوﻻﻳﺔ ﻳﺑﻳن ﻋﻣر ﻣﻘدم اﻟطﻠب
❖ ﺷﻬﺎدة ﻣﻳﻼد اﻣرﻳﻛﻳﺔ
وﺟﻧﺳﻳﺗﻪ اﻷﻣرﻳﻛﻳﺔ او ﻣﻛﺎن وﻻدﺗﻪ
❖ ﺷﻬﺎدة اﻗرار وﻻدة
(DS-1350)
*❖ ﺳﺟل ﺗﻌداد ﺳﻛﺎﻧﻲ ﻟﻘﺑﺎﺋل اﻟﻬﻧود اﻟﺳﻳﻧﻛﺎ
†
❖ اﻗرار وﻻدة ﺧﺎرﺟﻲ ﻷﻣرﻳﻛﻲ اﻟﺟﻧﺳﻳﺔ
(FS-240)
*❖ ﺳﺟل ﺗﻌداد ﺳﻛﺎﻧﻲ ﻣن ﻣﻛﺗب ﻗﺑﺎﺋل ﺷؤؤن اﻟﻬﻧود ﻟﻠﻬﻧود اﻟﻧﺎﻓﺎﺟو
†
أو
❖ ﺷﻬﺎدة وﻻدة ﺻﺎدرة ﻣن ﻗﺑل وزارة اﻟﺧﺎرﺟﻳﺔ
(DS-1350
FS-545)
*❖ ﺗﺑﻠﻳﻎ ﺑﺣﺎﻟﺔ وﻻدة ﻣﺳﺟﻠﺔ ﺑداﺋرة رﺳﻣﻳﺔ ﻓﻲ اﻟوﻻﻳﺎت اﻟﻣﺗﺣدة
†
أو
❖ ﺑطﺎﻗﺔ اﻟﻬوﻳﺔ اﻟﺷﺧﺻﻳﺔ ﻟﻠﻣواطن اﻷﻣرﻳﻛﻲ
(I-179
I-197)
❖ ﺳﺟل وﻻدة اﻣرﻳﻛﻲ ﻋﺎم ﻣ ُﻌدل واﻟذي ﺗم ﺗﻌدﻳﻠﻪ ﺑﻌد اﻛﺛر ﻣن
5
❖ ﺑطﺎﻗﺔ اﻟﻬﻧود اﻷﻣرﻳﻛﻳن
(I-872)
*ﺳﻧوات ﻣن ﺗﺎرﻳﺦ وﻻدة اﻟﺷﺧص
†
❖ ﺑطﺎﻗﺔ ﻣﺎرﻳﺎﻧﺎ ﺷﻣﺎﻟﻳﺔ
(I-873)
*❖ ﺷﻬﺎده ﻣوﻗﻌﻪ ﻣن اﻟطﺑﻳب او اﻟﻘﺎﺑﻠﺔ اﻟﻘﺎﻧوﻧﻳﺔ اﻟﻣﺗواﺟد اﺛﻧﺎء اﻟوﻻده
†
❖ إﻗرار ﺗﺑﻧﻲ ﻧﻬﺎﺋﻲ ﻳﺑﻳن ﻣﻛﺎن اﻟوﻻدة ﻓﻲ أﻣرﻳﻛﺎ
*❖ اﺛﺑﺎت اﻻﺻل اﻻﻵﺳﻛﻲ ﻣن ﺳﺟل ﺷؤون اﻟﻬﻧود اﻻﺻﻠﻳﻳن
†
❖ اﺛﺑﺎت اﻟﺗﺑﻧﻲ ﻟﻠطﻔل اﻟﻣوﻟود ﺧﺎرج اﻟوﻻﻳﺎت اﻟﻣﺗﺣده وﺑﺣﺿﺎﻧﺔ
❖ اوراق ﺗﺳﺟﻳل ﻣن ﻣرﻛز ﺗﻣرﻳض او ﻣرﻛز ﻋﻧﺎﻳﺔ ﺻﺣﻳﺔ، او اي
أو
ﻗﺎﻧوﻧﻳﻪ/ ﻓﻌﻠﻳﺔ ﻟواﻟدﻳن ﻳﺣﻣﻼن اﻟﺟﻧﺳﻳﺔ اﻻﻣرﻳﻛﻳﺔ
(IR-4
IR-3)
*ﻣؤﺳﺳﺔ ﺗﺑﻳن ﻣﻛﺎن اﻟوﻻدة ﻓﻲ اﻣرﻳﻛﺎ
❖ اﺛﺑﺎت اﻟﺗوظﻳف ﻓﻲ اﻟﺧدﻣﺔ اﻟﻣدﻧﻳﺔ ﻓﻲ اﻟوﻻﻳﺎت اﻟﻣﺗﺣده ﻓﻲ ﻣﺎ ﻗﺑل
*
ﻟﻳس ﺳﺟل ﺗطﻌﻳﻣﺎت
❖ ﺳﺟل طﺑﻲ
†
(
)
،
ﺣزﻳران
1976
1
*
ﺳﻧوات ﻗﺑل ﺗﺎرﻳﺦ اول طﻠب ﻟـ
ﻳﺟب ان ﻳﻛون ﺗﺎرﻳﺧﻪ ﻋﻠﻰ اﻻﻗل
5
❖ ﻣﻠف اﻟﺧدﻣﺔ اﻟﻌﺳﻛرﻳﻪ ﻓﻲ اﻟوﻻﻳﺎت اﻟﻣﺗﺣده ﻳﺑﻳن ﻣﻛﺎن اﻟوﻻده ﻓﻲ
.وﻳﺑﻳن ﻣﻛﺎن اﻟوﻻدة ﻓﻲ اﻣرﻳﻛﺎ
Medi-Cal
اﻟوﻻﻳﺎت اﻟﻣﺗﺣدة
.ﺳﻧﺔ، ﻳﺟب أن ﺗ ُﺻدر ﻗرب وﻗت اﻟوﻻدة
ﻟﻠطﻔل ﺗﺣت ﻋﻣر
16
†
*❖ ﺳﺟل طﺑﻲ ﻣن ﻣﺳﺗﺷﻔﻰ أﻣرﻳﻛﻲ ﺟُ ﻬ ﱢز ﻓﻲ وﻗت اﻟوﻻدة
†
†
*❖ ﺳﺟل ﺗﺄﻣﻳن ﻋﻠﻰ اﻟﺣﻳﺎة، اﻟﺻﺣﺔ، أو اي ﺳﺟل ﺗﺎﻣﻳن
.ﺗﻌطﻰ اﻻوﻟوﻳﺔ ﻟﻠوﺛﺎﺋق ﺣﺳب ﺗرﺗﻳﺑﻬﺎ ﻓﻲ اﻟﻘﺎﺋﻣﺔ
❖ اﻟﺳﺟل اﻟدﻳﻧﻲ اﻟﻣﺳﺟل ﻓﻲ اﻟوﻻﻳﺎت اﻟﻣﺗﺣده ﺧﻼل اﻻﺷﻬر اﻟﺛﻼﺛﻪ
....اذا ﻟم ﻳﻛن ﺑﺎﺳﺗطﺎﻋﺗك ﺗﻘدﻳم اي ﻣن وﺛﺎﺋق اﻟﺟﻧﺳﻳﺔ
اﻻوﻟﻰ ﻣن اﻟوﻻده واﻟذي ﻳﺛﺑت ﻣﻛﺎن اﻟوﻻده ﻓﻲ اﻟوﻻﻳﺎت اﻟﻣﺗﺣده
اطﻠب ﻣن ﺷﺧﺻﻳن ﺑﺎﻟﻐﻳن ﺗﻌﺑﺋﺔ وﺗوﻗﻳﻊ اﻗرار اﺛﺑﺎت ﺟﻧﺳﻳﺔ. ﻳﺟب ان
وﺗﺎرﻳﺦ اﻟوﻻده أواﻟﻌﻣر
ﻳﻣﻠك ﻛﻼ اﻟﺑﺎﻟﻐﻳن وﺛﻳﻘﺔ اﺛﺑﺎت ﺟﻧﺳﻳﺔ اﻣرﻳﻛﻳﺔ و اﺛﺑﺎت ﺷﺧﺻﻳﺔ، وﻳﻣﻛن
❖ اﻟﺳﺟل اﻟﻣدرﺳﻲ اﻟﻣﺑﻛر اﻟذي ﻳﺑﻳن ﻣﻛﺎن اﻟوﻻده ﻓﻲ اﻟوﻻﻳﺎت اﻟﻣﺗﺣده
.ان ﻳﻛون واﺣد ﻓﻘط ﻣﻧﻬم ﻣن اﻗرﺑﺎﺋك
. ﺗﺎرﻳﺦ اﻻﻟﺗﺣﺎق، ﺗﺎرﻳﺦ اﻟﻣﻳﻼد، اﺳﻣﺎء وﻣﻛﺎن وﻻدة اﻻﺑوﻳن
و
–
–
:واﺣدة ﻣن وﺛﺎﺋق اﺛﺑﺎت اﻟﺷﺧﺻﻳﺔ ﻣن اﻟﻧﻘﺎط اﻟﺗﺎﻟﻳﺔ
❖ رﺧﺻﺔ ﻗﻳﺎدة ﺻﺎدرة ﻣن وﻻﻳﺔ أو ﻣﻘﺎطﻌﺔ اﻣرﻳﻛﻳﺔ ﻣﻊ ﺻورة أو
❖ ﻫوﻳﺔ ﻗﺎﺻر ﺗﺎﺑﻊ ﻟوﻟﻲ أﻣر ﻳﺧدم ﻓﻲ اﻟﻌﺳﻛرﻳﺔ اﻷﻣرﻳﻛﻳﺔ
اي ﻣﻌﻠوﻣﺎت ﺷﺧﺻﻳﺔ
ﺻﺎدر ﺑﺷروط
❖ ﺟواز ﺳﻔر اﻣرﻳﻛﻲ
(
)
❖ ﻫوﻳﺔ ﻣدرﺳﻳﺔ ﻣﻊ ﺻورة
❖ ﺷﻬﺎدة اﺛﺑﺎت ﻧﺳب اﺻل ﻫﻧدي أو اي وﺛﻳﻘﺔ اﺛﺑﺎت ﺟﻧﺳﻳﺔ ﻣن
❖ ﻫوﻳﺔ اﻟﺧدﻣﺔ اﻟﻌﺳﻛرﻳﺔ اﻷﻣرﻳﻛﻳﺔ أو ﺑطﺎﻗﺔ اﻟﺗﺟﻧﻳد اﻷﺟﺑﺎري
ﻗﺑﺎﺋل اﻣرﻳﻛﻳﺔ ﻫﻧدﻳﺔ/أو ﻣن اﻻﺳﻛﺎ
❖ ﻫوﻳﺔ ﻓﻳدﻳراﻟﻳﺔ، أو ﻣن اﻟوﻻﻳﺔ او ﻣن اﻟﺣﻛوﻣﺔ اﻟﻣﺣﻠﻳﺔ ﻟﻣﻛﺎن
❖ ﺑطﺎﻗﺔ ﺣرس اﻟﺳﺎﺣل اﻟﺑﺣري اﻷﻣرﻳﻛﻲ
اﻷﻗﺎﻣﺔ ﺗﺣﺗوي ﻋﻠﻰ ﻧﻔس اﻟﻣﻌﻠوﻣﺎت اﻟﺷﺧﺻﻳﺔ اﻟﻣوﺟودة ﻋﻠﻰ
رﺧﺻﺔ اﻟﻘﻳﺎدة
DHCS 0001 (01/08) – Arabic
Page 3 of 4
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