Citizenship Affidavit Form - Washington
HCA 27-033 (5/12)
CITIZENSHIP AFFIDAVIT
•
This affidavit is to be used only if you are unable to provide primary proof of citizenship, such as a passport or birth certificate.
•
To be eligible for Medicaid, you
must
complete and sign
two
Citizenship Affidavit forms.
o
Only
one
person affirming your citizenship can be related to you.
•
If requested,
each friend or relative
signing the Citizen Affidavit form in support of the client must provide proof of:
o
Citizenship (birth certificate); and
o
Identity (examples: driver’s license, military ID, state ID).
CLIENT
NAME (OTHER KNOWLEDGEABLE PERSON, IF APPLICABLE)
CLIENT ID NUMBER
I am unable to provide/obtain a birth certificate or other documentary proof of citizenship because:
I declare, under penalty of perjury of the laws of the State of Washington, the information in this affidavit is true
and correct.
CLIENT SIGNATURE
Signed this day of 20 ,
at Washington.
FRIEND OR RELATIVE
NAME (PLEASE PRINT)
RELATIONSHIP TO CLIENT (IF ANY)
I know that the client listed above is a United States citizen because:
I declare, under penalty of perjury of the laws of the State of Washington, the information in this affidavit is true
and correct.
SIGNATURE
Signed this day of 20 ,
at Washington.
Page 1/1
Free Download
Citizenship Affidavit Form - Washington PDF
Favor this template? Just fancy it by voting!
(0 Votes)
0.0
Related Forms
