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Fillable Printable Citizenship Affidavit Form - Washington

Fillable Printable Citizenship Affidavit Form - Washington

Citizenship Affidavit Form - Washington

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.
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