“IMPORTANT INFORMATION ABOUT RESIDENCY”
Medi-Cal applicants who have one of the items listed below MUST provide it as evidence
of residency. Medi-Cal applicants who DO NOT have one of the items listed below must
sign this page AND provide other evidence of residency. DO NOT SIGN THIS PAGE IF
YOU HAVE ONE OF THE ITEMS LISTED BELOW.
I UNDERSTAND that the welfare department will only consider evidence other than the
items listed below if I do not have one of the following items:
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A recent California rent or mortgage receipt or utility bill in my name.
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A current and valid California Motor Vehicle Driver’s License or California Identification
Card issued by the California Department of Motor Vehicles.
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A current and valid California motor vehicle registration in my name.
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A document showing that I am employed in this State.
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A document showing that I have registered with a public or private employment service
in this State.
!
Evidence that I have enrolled myself or my children in a school in this State.
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Evidence that I am receiving public assistance other than Medi-Cal in this State.
!
Evidence that I have registered to vote in this State.
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF
CALIFORNIA THAT I DO NOT POSSESS ANY OF THE ITEMS LISTED ABOVE.
Applicant signature Date
Person acting for applicant (signature) Date
MC 214 (05/07)
State of California—Health and Human Services Agency Department of Health Care Services
