Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Tagalog) Page 9

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State of California—Health and Human Services Agency
Department of Health Care Services
Ilista ang posisyon sa trabaho ng bata at dagliang ilarawan ang trabaho at anumang mga problema na maaaring nagkaroon ang bata habang
nagtatrabaho.
BAHAGI 9—MGA PUNA
BAHAGI 10—PIRMA AT PAGPAPATUNAY
Aking ipinapahayag na sa ilalim ng kaparusahan ng panunumpa nang walang katotohanan sa ilalim ng batas ng State of California na ang mga sagot na
aking ibinigay sa Supplemental Statement of Facts for Medi-Cal form na ito at ang mga dokumento na ibinigay ay tama at totoo sa lubos ng aking kaalaman at
paniniwala.
1. Pirma ng Tao na naga-apply para sa bata
Kaugnayan sa bata
Petsa
Address (numero, kalye)
Lungsod
Estado
Zip Code
Numero ng Telepono
2. Pirma ng saksi (kung angkop)
Kaugnayan ng tao na naga-apply para sa bata
Petsa
Address (numero, kalye)
Lungsod
Estado
Zip Code
Numero ng Telepono
Pahina 9 ng 9
MC 223C_TAG_0611

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