Fillable MEDI-CAL RESIDENCY DECLARATION (Department of Health Care Services)

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MEDI-CAL RESIDENCY DECLARATION (Department of Health Care Services)

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State of California—Health and Human Services Agency Department of Health Care Services
MEDI-CAL RESIDENCY
DECLARATION
(COUNTY STAMP)
Date: ________________________________
Case name: __________________________
Case number: _________________________
_________________________Worker name:
District: ______________________________
EVERY APPLICANT FOR MEDI-CAL IS REQUIRED TO ANSWER THE FOLLOWING QUESTIONS ABOUT
RESIDENCY. PLEASE ANSWER “YES” OR “NO” TO QUESTIONS ONE THROUGH SIX AND SIGN AND DATE THE
FORM BELOW.
YES NO
1. Do you or any family member own, lease, or maintain a home outside California? ❒ ❒
2. Are you or any family member currently receiving public assistance from outside California? ❒ ❒
3. Are you or any family member living outside California? ❒ ❒
4. Are you or any family member in the United States on a Visa or a Border Crossing Card? ❒ ❒
5. Are you or any family member planning to leave California for more than 60 days? ❒ ❒
6. Do you and your family plan to stay permanently in California? ❒ ❒
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE
ANSWERS I HAVE GIVEN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Applicant signature Date
Signature of person acting for applicant Date
MC 212 (05/07)
State of California—Health and Human Services Agency Department of Health Care Services
DECLARACIÓN DE MEDI-CAL
SOBRE RESIDENCIA
(COUNTY STAMP)
Fecha:_______________________________
Nombre del caso: ______________________
Número del caso: ______________________
Nombre del Trabajador(a): _______________
Distrito: ______________________________
A CADA UNO DE LOS SOLICITANTES DE BENEFICIOS DE MEDI-CAL SE LES EXIGE CONTESTAR LAS
SIGUIENTES PREGUNTAS ACERCA DE SU RESIDENCIA. POR FAVOR CONTESTE “SÍ” O “NO” A LAS PREGUNTAS
UNA A SEIS, Y FIRME Y ANOTE LA FECHA EN LA PARTE INFERIOR DEL FORMULARIO.
SÍ NO
1. ¿Usted o algún familiar es propietario, renta o mantiene una casa fuera de California? ❒ ❒
2. ¿Usted o algún familiar recibe actualmente asistencia pública de otro lugar fuera de California? ❒ ❒
3. ¿Vive fuera de California usted o algún familiar? ❒ ❒
4. ¿Está usted o algún familiar en los Estados Unidos gracias a una Visa o a una Tarjeta para Cruzar la Frontera? ❒ ❒
5. ¿Planea usted o algún familiar salir de California por más de 60 días? ❒ ❒
6. ¿Planean usted y su familia permanecer en California permanentemente? ❒ ❒
DECLARO BAJO PENA DE PERJURIO EN CONFORMIDAD CON LAS LEYES DEL ESTADO DE CALIFORNIA QUE
LAS RESPUESTAS QUE HE PROPORCIONADO SON VERDADERAS Y CORRECTAS SEGÚN MI ENTENDER.
Firma del solicitante Fecha
Firma de la persona que actúa en nombre del solicitante Fecha
MC 212 (SP) (05/07)
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MEDI-CAL RESIDENCY DECLARATION (Department of Health Care Services)

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Completed 30 July 2020

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