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

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State of California – Health and Human Services Agency
Department of Health Care Services
‫ﺷﻬﺎدة ﺧﻄ ﻴ ّﺔ ﺑﺈﺛﺒﺎت ﻫﻮﻳﺔ ﻃﻔﻞ ﲢﺖ ﺳﻦ اﻟـ 81 ﻛﻤﻮاﻃﻦ اﻣﺮﻳﻜﻲ او ﻳﺤﻤﻞ اﳉﻨﺴﻴﺔ اﻻﻣﺮﻳﻜﻴﺔ‬
:(‫ﻟﻠﻮاﻟﺪﻳﻦ أواﻟﻮﺻﻲ أو وﻛﻴﻞ ﻣﻦ اﻻﻗﺮﺑﺎء )ﻗﺮﻳﺐ ﻳﻌﺘﻨﻲ ﺑﺎﻟﻄﻔﻞ‬
:‫ﳝﻜﻨﻚ اﺳﺘﺨﺪام ﻫﺬا اﻟﻨﻤﻮذج ﻓﻲ ﺣﺎل اذا‬
‫ﻟﻢ ﻳﻜﻦ ﻟﺪﻳﻚ وﺛﻴﻘﺔ إﺛﺒﺎت ﺷﺨﺼﻴﺔ ﻟﻄﻔﻞ ﻣﺎ دون اﻟـ‬
16
‫أو‬
•
‫ﻟﻢ ﻳﻜﻦ ﻟﺪﻳﻚ ﻫﻮﻳﺔ ﻣﺪرﺳﺔ أو رﺧﺼﺔ ﺳﻮاﻗﺔ ﻟﻄﻔﻞ ﻣﺎ دون اﻟـ‬
.
18
•
.‫اﻣﻸ ووﻗﻊ اﻟﻨﻤﻮذج اﻟﺘﺎﻟﻲ. أﻛﺘﺐ ﺑﺄﺣﺮف ﻛﺒﻴﺮة وﺑﺨﻂ واﺿﺢ وﺳﻠﻤﻪ اﻟﻰ ﻣﻜﺘﺐ اﳋﺪﻣﺎت اﻻﺟﺘﻤﺎﻋﻴﺔ اﶈﻠﻲ‬
.‫ﻣﻬﻢ! ﻻ ﳝﻜﻨﻚ ﺗﻌﺒﺌﺔ ﻫﺬا اﻟﻨﻤﻮذج اذا ﺳﺒﻖ وﻗﺪﻣﺖ ﺷﻬﺎدة ﺧﻄﻴﺔ ﻹﺛﺒﺎت اﳉﻨﺴﻴﺔ ﻟﻬﺬا اﻟﻄﻔﻞ أو ﻟﻬﺆﻻء اﻷﻃﻔﺎل‬
‫ﻣﻌﻠﻮﻣﺎت اﻟﻮاﻟﺪ أواﻟﻮاﻟﺪة‬
:
‫اﺳﻢ اﻟﻮاﻟﺪ أواﻟﻮاﻟﺪة‬
(‫)أو اﻟﻮﺻﻲ أو اﻟﻮﻛﻴﻞ‬
‫اﻷﺧﻴﺮ‬
‫اﻟﻮﺳﻂ‬
‫اﻷول‬
:‫اي اﺳﻤﺎء اﺧﺮى ﻣﺴﺘﺨﺪﻣﺔ‬
‫اﻷﺧﻴﺮ‬
‫اﻟﻮﺳﻂ‬
‫اﻷول‬
:(‫اذا ﻛﻨﺖ ﻣﻦ اﻟﻌﺎﺋﻠﺔ وﻣﻮﻛﻞ ﺑﻌﻨﺎﻳﺔ اﻟﻄﻔﻞ، ﻣﺎ ﻫﻲ ﻋﻼﻗﺘﻚ ﺑﺎﻟﻄﻔﻞ؟ )اﺧﺘﺮ واﺣﺪة‬
____________________________________:(‫® ﺟﺪ أو ﺟﺪة ® ﻋﻢ أو ﻋﻤﺔ/ﺧﺎل أو ﺧﺎﻟﺔ ® أخ/أﺧﺖ ® آﺧﺮ )اﺷﺮح‬
‫ﻣﻌﻠﻮﻣﺎت اﻟﻄﻔﻞ‬
:‫ﺳﻨﺔ‬
18
‫اﺳﻢ اﻟﻄﻔﻞ ﲢﺖ ﻋﻤﺮ‬
‫اﻷﺧﻴﺮ‬
‫اﻟﻮﺳﻂ‬
‫اﻷول‬
:‫ﺗﺎرﻳﺦ وﻣﻜﺎن وﻻدة اﻟﻄﻔﻞ‬
(‫اﻟﻮﻻﻳﺔ )أو اﻟﺒﻠﺪ اﻷﺟﻨﺒﻲ‬
‫ﺷﻬﺮ/ ﻳﻮم/ ﺳﻨﺔ‬
‫اﳌﺪﻳﻨﺔ‬
‫ﻣﻌﻠﻮﻣﺎت ﻃﻔﻞ اﺧﺮ‬
(‫)اذا ﻛﺎن ﻣﻄﺎﺑﻘ ﺎ ً ﻟﻠﺸﺮوط‬
:‫ﺳﻨﺔ‬
18
‫اﺳﻢ اﻟﻄﻔﻞ اﻷﺧﺮﲢﺖ ﻋﻤﺮ‬
‫اﻷﺧﻴﺮ‬
‫اﻟﻮﺳﻂ‬
‫اﻷول‬
:‫ﺗﺎرﻳﺦ وﻣﻜﺎن وﻻدة اﻟﻄﻔﻞ اﻷﺧﺮ‬
(‫اﻟﻮﻻﻳﺔ )أو اﻟﺒﻠﺪ اﻷﺟﻨﺒﻲ‬
‫ﺷﻬﺮ/ ﻳﻮم/ ﺳﻨﺔ‬
‫اﳌﺪﻳﻨﺔ‬
‫ﻣﻌﻠﻮﻣﺎت ﻃﻔﻞ اﺧﺮ‬
(‫)اذا ﻛﺎن ﻣﻄﺎﺑﻘ ﺎ ً ﻟﻠﺸﺮوط‬
:‫ﺳﻨﺔ‬
18
‫اﺳﻢ اﻟﻄﻔﻞ اﻷﺧﺮﲢﺖ ﻋﻤﺮ‬
‫اﻷﺧﻴﺮ‬
‫اﻟﻮﺳﻂ‬
‫اﻷول‬
:‫ﺗﺎرﻳﺦ وﻣﻜﺎن وﻻدة اﻟﻄﻔﻞ اﻷﺧﺮ‬
(‫اﻟﻮﻻﻳﺔ )أو اﻟﺒﻠﺪ اﻷﺟﻨﺒﻲ‬
‫ﺷﻬﺮ/ ﻳﻮم/ ﺳﻨﺔ‬
‫اﳌﺪﻳﻨﺔ‬
.‫اذا ﻛﺎن ﻟﺪﻳﻚ أﻛﺜﺮ ﻣﻦ ﺛﻼﺛﺔ أﻃﻔﺎل، اﻟﺮﺟﺎء ﻣﻠﻰء وارﺳﺎل ﳕﻮذج آﺧﺮ‬
:‫اﻗﺮأ ووﻗﻊ ادﻧﺎه‬
.‫اﻗﺮ ﲢﺖ ﻃﺎﺋﻠﺔ اﳌﺴﺆوﻟﻴﺔ ﻟﻘﺎﻧﻮن وﻻﻳﺔ ﻛﺎﻟﻴﻔﻮرﻧﻴﺎ ﺻﺤﺔ وﺻﺪق اﳌﻌﻠﻮﻣﺎت اﳌﺬﻛﻮرة أﻋﻼه‬
:‫اﻟﺘﺎرﻳﺦ‬
‫ﺗﻮﻗﻴﻊ اﻟﻮاﻟﺪﻳﻦ أو اﻟﻮﺻﻲ أو اﻟﻮﻛﻴﻞ ﻣﻦ اﻻﻗﺮﺑﺎء‬
DHCS 0009 (Arabic) (09/07)
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