State of California – Health and Human Services Agency Department of Health Care Services
Affidavit of Reasonable Effort to Get Proof of Citizenship
Fill out below
I am trying to get proof of citizenship for
First Middle Last
I have tried to get proof of citizenship from the people or agencies listed below.
(Also list dates of contact and how long it will take to get the proof of citizenship.)
Name of person or
agency contacted
Date they will
Explain below any other information about your efforts to get proof of citizenship:
Your name (print)
Your signature Date
If you need help with this form, please call your local social services office.
County fills out this box
Case Name:
If this Affidavit is taken on the phone, fill out below:
Case No:
County worker’s name and signature Date
DHCS 0003 (06/07) Page 1 of 1
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