Effective Date: 
11/2006

Documents


Instructions

Updated: 9/2007

Purpose

To provide documentation of

  • citizenship, either by birth or naturalization, for an individual of any age.
  • identity for a child under age 16.
  • identity for a disabled individual in a residential care facility.

Procedure

When to Prepare

The affidavit is to be used as a last resort when the Medicaid applicant or recipient is unable to provide other documentation of citizenship or identity.

Detailed Instructions

Note:The affiant is the individual certifying the facts contained in the affidavit.

When used to document citizenship:

  • The affidavit must be completed by two adults, regardless of their relationship to the Medicaidapplicant/recipient.
  • The affiant must complete all the blanks in Part A.
  • The applicant/recipient (parent/guardian if for a child under age 18) or applicant/recipient'sauthorized representative must complete all the blanks in Part B.

When used to document identity for a child under age 16, the parent or guardian of the child must complete all the blanks in Part A, except for the section addressing why the applicant is unable to produce documentary evidence of citizenship. Completion of Part B is not required.

When used to document identity for a disabled individual in a residential care facility, the facility director or administrator must attest to identity of the individual.

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