Form Dhcs 0009 - Affidavit Of Identity For U.s. Citizen Or National Children Under 18 - Farsi

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State of California – Health and Human Services Agency
Department of Health Care Services
‫اﻗﺮارﻧﺎﻣﻪ ﺗﺄﻳﻴﺪ ﻫﻮﻳﺖ ﻓﺮزﻧﺪان ﺧﺎرﺟﻲ ﻳﺎ ﺳ ﺘ زن زﻳﺮ 81 ﺳﺎل‬
:(‫ﺑﻪ واﻟﺪ٬ ﺳﺮﭘﺮﺳﺖ٬ ﻳﺎ ﻋﻀﻮ ﺧﺎﻧﻮاده ﻧﮕﻬﺪاري ﻛﻨﻨﺪه )ﻳﻜﻲ از اﻓﺮاد ﻓﺎﻣﻴﻞ ﻛﻪ از ﻛﻮدك ﻧﮕﻬﺪاري ﻣﻲ ﻛﻨﺪ‬
:‫ﺷﻤﺎ در ﺻﻮرﺗﻲ ﻣﻲ ﺗﻮاﻧﻴﺪ از اﻳﻦ ﻓﺮم اﺳﺘﻔﺎده ﻛﻨﻴﺪ ﻛﻪ‬
‫ﺳﺎل ﻧﺪارﻳﺪ٬ ﻳﺎ‬
16
‫• ﺷﻤﺎ ﻫﻴﭻ ﺳﻨﺪ ﻫﻮﻳﺘﻲ ﺑﺮاي ﻛﻮدك زﻳﺮ‬
.‫ﺳﺎل ﻧﺪارﻳﺪ‬
18
‫• ﺷﻤﺎ ﻛﺎرت ﺷﻨﺎﺳﺎﺋﻲ ﻣﺪرﺳﻪ ﻳﺎ ﮔﻮاﻫﻴﻨﺎﻣﻪ راﻧﻨﺪﮔﻲ ﺑﺮاي ﺷﺨﺺ زﻳﺮ‬
.‫ﻓﺮم زﻳﺮ را ﭘﺮ ﻛﺮده و زﻳﺮ آﻧﺮا اﻣﻀﺎ ﻛﻨﻴﺪ. آﻧﺮا ﺑﺎ ﺧﻂ ﺧﻮاﻧﺎ ﻧﻮﺷﺘﻪ و ﺑﻪ دﻓﺘﺮ ﺧﺪﻣﺎت اﺟﺘﻤﺎﻋﻲ ﻛﺎﻧﺘﻲ ﺧﻮد ﺗﺴﻠﻴﻢ ﻛﻨﻴﺪ‬
‫ﻧﻜﺘﻪ ﻣﻬﻢ! ﭼﻨﺎﻧﭽﻪ ﻳﻚ اﻗﺮارﻧﺎﻣﻪ ﺳﻴﺘﻲ زن ﺷﻴﭙﻲ ﺑﺮاي ﻓﺮزﻧﺪ/ان ﻗﻴﺪ ﺷﺪه در زﻳﺮ ﭘﺮ ﻛﺮده اﻳﺪ دﻳﮕﺮ ﳕﻲ ﺗﻮاﻧﻴﺪ اﻳﻦ‬
.‫ﻓﺮم را ﭘﺮ ﻛﻨﻴﺪ‬
‫اﻃﻼﻋﺎت واﻟﺪ‬
:
‫ﻧﺎم واﻟﺪ‬
(‫)ﻳﺎ ﺳﺮﭘﺮﺳﺖ ﻳﺎ ﻋﻀﻮ ﺧﺎﻧﻮاده ﻧﮕﻬﺪاري ﻛﻨﻨﺪه‬
‫ﻧﺎم ﺧﺎﻧﻮادﮔﻲ‬
‫ﻧﺎم وﺳﻂ‬
‫ﻧﺎم‬
:‫ﻧﺎﻣﻬﺎي دﻳﮕﺮ اﺳﺘﻔﺎده ﺷﺪه‬
‫ﻧﺎم ﺧﺎﻧﻮادﮔﻲ‬
‫ﻧﺎم وﺳﻂ‬
‫ﻧﺎم‬
:(‫اﮔﺮ ﺷﻤﺎ ﻳﻚ ﻋﻀﻮ ﺧﺎﻧﻮاده ﻧﮕﻬﺪاري ﻛﻨﻨﺪه از ﻛﻮدك ﻫﺴﺘﻴﺪ٬ ﻧﺴﺒﺖ ﺷﻤﺎ ﺑﺎ ﻛﻮدك ﭼﻴﺴﺖ؟ )ﻳﻜﻲ را ﻋﻼﻣﺖ ﺑﺰﻧﻴﺪ‬
:(‫® دﻳﮕﺮ )ﺗﻮﺿﻴﺢ دﻫﻴﺪ‬
‫® ﭘﺪرﻳﺎ ﻣﺎدرﺑﺰرگ ® ﻋﻤﻮ/ﻋﻤﻪ/ﺧﺎﻟﻪ/داﺋﻲ ® ﺧﻮاﻫﺮ/ﺑﺮادر‬
‫اﻃﻼﻋﺎت ﻓﺮزﻧﺪ‬
:‫ﻧﺎم ﻓﺮزﻧﺪ زﻳﺮ 81 ﺳﺎل‬
‫ﻧﺎم ﺧﺎﻧﻮادﮔﻲ‬
‫ﻧﺎم وﺳﻂ‬
‫ﻧﺎم‬
:‫زﻣﺎن و ﻣﻜﺎن ﺗﻮﻟﺪ ﻓﺮزﻧﺪ‬
(‫اﻳﺎﻟﺖ )ﻳﺎ ﻛﺸﻮر ﺧﺎرﺟﻲ‬
‫ﺳﺎل/ روز/ ﻣﺎه‬
‫ﺷﻬﺮ‬
‫اﻃﻼﻋﺎت ﻓﺮزﻧﺪ دﻳﮕﺮ‬
(‫)اﮔﺮ ﻗﺎﺑﻞ اﻃﻼق ﺑﺎﺷﺪ‬
:‫ﻧﺎم ﻓﺮزﻧﺪ دﻳﮕﺮ زﻳﺮ 81 ﺳﺎل‬
‫ﻧﺎم ﺧﺎﻧﻮادﮔﻲ‬
‫ﻧﺎم وﺳﻂ‬
‫ﻧﺎم‬
:‫زﻣﺎن و ﻣﻜﺎن ﺗﻮﻟﺪ ﻓﺮزﻧﺪ دﻳﮕﺮ‬
(‫اﻳﺎﻟﺖ )ﻳﺎ ﻛﺸﻮر ﺧﺎرﺟﻲ‬
‫ﺳﺎل/ روز/ ﻣﺎه‬
‫ﺷﻬﺮ‬
‫اﻃﻼﻋﺎت ﻓﺮزﻧﺪ دﻳﮕﺮ‬
(‫)اﮔﺮ ﻗﺎﺑﻞ اﻃﻼق ﺑﺎﺷﺪ‬
:‫ﻧﺎم ﻓﺮزﻧﺪ دﻳﮕﺮ زﻳﺮ 81 ﺳﺎل‬
‫ﻧﺎم ﺧﺎﻧﻮادﮔﻲ‬
‫ﻧﺎم وﺳﻂ‬
‫ﻧﺎم‬
:‫زﻣﺎن و ﻣﻜﺎن ﺗﻮﻟﺪ ﻓﺮزﻧﺪ دﻳﮕﺮ‬
(‫اﻳﺎﻟﺖ )ﻳﺎ ﻛﺸﻮر ﺧﺎرﺟﻲ‬
‫ﺳﺎل/ روز/ ﻣﺎه‬
‫ﺷﻬﺮ‬
.‫اﮔﺮ ﺷﻤﺎ ﺑﻴﺶ از ﺳﻪ ﻛﻮدك دارﻳﺪ٬ ﻳﻚ ﻓﺮم دﻳﮕﺮ ﭘﺮ ﻛﺮده و ﺗﺴﻠﻴﻢ ﻛﻨﻴﺪ‬
:‫ﻗﺴﻤﺖ زﻳﺮ را ﺧﻮاﻧﺪه و اﻣﻀﺎء ﻛﻨﻴﺪ‬
.‫ﻣﻦ ﺑﺎ ﻗﺒﻮل ﻣﺴﺌﻮﻟﻴﺖ ﻫﺎي ﻗﺎﻧﻮﻧﻲ ﺷﻬﺎدت دروغ ﲢﺖ ﻗﻮاﻧﲔ اﻳﺎﻟﺘﻲ ﻛﺎﻟﻴﻔﺮﻧﻴﺎ اﻋﻼم ﻣﻲ ﻛﻨﻢ ﻛﻪ اﻃﻼﻋﺎت داده ﺷﺪه در ﺑﺎﻻ ﺣﻘﻴﻘﺖ ﺳﺎﺷﺘﻪ و ﺻﺤﻴﺢ ﻣﻲ ﺑﺎﺷﺪ‬
:‫ﺗﺎرﻳﺦ‬
‫اﻣﻀﺎي واﻟﺪ ٬ ﻳﺎ ﺳﺮﭘﺮﺳﺖ ﻳﺎ ﻋﻀﻮ ﺧﺎﻧﻮاده ﻧﮕﻬﺪاري ﻛﻨﻨﺪه‬
DHCS 0009 (Farsi) (09/07)
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