Form Dhcs 0003 - California Daim Ntawv Teev Kev Nrhiav Tej Puavpheej Uas Qhia Tias Yog Neeg Amelikas - Health And Human Services Agency

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State of California – Health and Human Services Agency
Department of Health Care Services
Daim Ntawv Teev Kev Nrhiav Tej Puavpheej Uas Qhia Tias Yog Neeg Amelikas
Ua cov hauv qab no
(sau ua tej tus tsiaj ntawv)
Kuv tseem tabtom nrhiav tej puavpheej uas qhia tias yog neeg Amelikas rau
(npe):
Npe
Npe nrab
Xeem
Kuv tau mus nrhiav tej puavpheej uas qhia tias yog neeg Amelikas ntawm cov tibneeg lossis koomhaum uas
teev rau hauv qab no.
(Sau hnub uas koj hu rau lossis mus ntsib lawv thiab yuav ntev npaum licas mam li tau tej puavpheej uas qhia tias yog
neeg Amelikas ntawd.)
Tus tibneeg lossis lub koomhaum
Yam ntaub ntawv uas
Hnub hu rau lossis
Hnub lawv yuav teb
uas hu rau lossis mus ntsib lub npe
nrhiav
mus ntsib
rov tuaj
Qhia rau hauv qab no txog lwm txoj kev uas koj tau mus nrhiav tej puavpheej uas qhia tias yog neeg Amelikas:
Koj lub npe (sau ua tej tus tsiaj ntawv)
Koj suam npe
Hnubtim
Yog koj xav tau kev pab ua daim ntawv no, hu rau koj lub chaw pabcuam pejxeem hauv nroog.
Lub county mam ua lub npov hauv qab no
County fills out this box
Case No:
Case Name:
If this Affidavit is taken on the phone, fill out below:
County worker’s name and signature
Date
DHCS 0003 (06/07) – Hmong
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