Updated: 6/29/10 REQUEST FOR PROOF OF ... - Healthy Kids: …

REQUEST FOR PROOF OF CITIZENSHIP

Updated: 6/29/10

REQUEST FOR PROOF OF U.S. CITIZENSHIP

If no other documentation of U.S. citizenship is available, (such as a U.S. birth certificate, U.S. passport, or Naturalization papers), copy this page and have two people verify U.S. citizenship for each person applying for or receiving KidCare. One of the two people cannot be a relative. Those two people must also attach a copy of the documents to verify their citizenship and identity.

NOTE: This document does not verify identity.

Please return the completed form to Florida KidCare, PO Box 591, Tallahassee, Florida 32302-0591. If you have any questions, please call Florida KidCare toll free at 1-800-821-5437.

Family Account Number: _____________________

1. My name is ______________________________________________________. I am a U.S. citizen and I have a personal knowledge of the facts stated in this document.

2. I have personal knowledge of the circumstances that establish _________________________________ ________________________________________(Name of applicant/recipient) as a United States Citizen. The facts known to me are as follows (for example, date and place of birth in the United States): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

3. Documentary evidence of citizenship was unavailable or does not exist because: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

___________________________________________________________________________________ I am attaching proof of my own U.S. citizenship and identity. I certify that the information provided is true and correct to the best of my knowledge. I understand that if I provide false information, I may be prosecuted for fraud.

_____________________________________ Signature

_______________________ Date

If #3 above is not completed, the applicant/recipient or representative must complete and sign the following statement:

The reason no other documents were available to prove U.S. citizenship for myself or a member of my household is: ___________________________________________________________________________ _______________________________________________________________________________________ I understand that I can be prosecuted if I do not tell the truth.

_____________________________________ Signature

_______________________ Date

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