HFS 3859 (R-5-10)
State of Illinois
Department of Healthcare and Family Services
STATEMENT OF IDENTITY
This form is for persons who are U.S. citizens
Case Name: Case ID:
Due to a change in Federal law, we must confirm the identity of each U.S. citizen who applies for or gets
medical benefits. Please provide ONE of the items listed below for each U.S. citizen for whom you are
requesting or getting medical benefits. These documents must be the originals or certified copies, we
are not allowed under federal rules to accept your photocopied documents.
• U.S. Passport
• Certificate of U.S. Citizenship
• (Form N-560 or N-561)
• U.S. military ID or draft record
• Native American Tribal document
with a photo or information such as name,
age, race, weight, height, eye color
• School ID card with photo
• State issued ID or driver's license
• Certificate of Naturalization (Form N-550 or N-570)
• Military dependent's card
• U.S. Coast Guard Merchant Mariner card
• ID card issued by federal, state, or local government
with photo or information such as name, age, race,
weight, height, eye color
FOR CHILDREN UNDER AGE 16 WHO ARE U.S. CITIZENS
School and daycare records are acceptable.
If you cannot get any of the documents listed above for children under age 16, please tell us the names of
the children below, and check the box to tell us if you are the child's parent or legal guardian. If you are not
the child's parent or legal guardian, check other and write in how you are related to the child.
Child's Full Name (First, Middle, Last)
Child's Date of Birth
Child's Place of Birth
City
State
Your Relationship to Child (Mark one)
Parent
Legal Guardian
Other
Child's Full Name (First, Middle, Last)
Child's Date of Birth
Child's Place of Birth
City
State
Your Relationship to Child (Mark one)
Parent
Legal Guardian
Other
Affidavit
I declare, under penalty of perjury, that the identity of persons listed above is correct.
Signature Date
If you have questions about this form, call your caseworker at
