Fillable Declaracin jurada de esfuerzo razonable para obtener prueba (Department of Health Care Services)

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Declaracin jurada de esfuerzo razonable para obtener prueba (Department of Health Care Services)

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State of California – Health and Human Services Agency Department of Health Care Services
Declaración jurada de esfuerzo razonable para obtener prueba de ciudadanía
Llene abajo
(en letra de molde)
Estoy tratando de obtener prueba de ciudadanía de
(nombre):
Primer nombre Segundo nombre Apellido
Traté de obtener prueba de ciudadanía de las personas o entidades indicadas abajo.
(Escriba también las fechas de contacto y cuánto tomará obtener la prueba de ciudadanía).
Nombre de la persona o de la agencia
con que se puso en contacto
Documento
solicitado
Fecha en que se
puso en contacto
Fecha en que
responderán
Escriba abajo la demás información, si la hay, sobre sus esfu
erzos para obtener prueba de ciudadanía:
Su nombre
(en letra de molde)
Su firma Fecha
Si necesita ayuda con este formulario, llame a la oficina local de servicios sociales.
El condado llenará la casilla a continuación
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) - Spanish
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Declaracin jurada de esfuerzo razonable para obtener prueba (Department of Health Care Services)

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Completed 23 November 2020

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