STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10161 (07/08)
ID
STATEMENT OF CITIZENSHIP AND / OR IDENTITY FOR SPECIAL POPULATIONS
Complete this form to allow the individual listed below to meet the Medicaid/BadgerCare Plus/Family Planning services proof of citizenship and identification rule only when no other proof exists or can be shown to prove citizenship or identity. Complete the appropriate section(s) below and return this form to your local county or tribal agency. Citizenship Statement By completing this section, I attest to the citizenship of the individual named below.
Print Name Applicant / Member
Date of Birth
Place of Birth (City and State)
Case or Social Security Number
By signing this statement I certify under penalty of perjury and false swearing that the information I have given is correct and complete to the best of my knowledge. I understand that I am only able to do this because I am a U.S. Citizen and I understand that the local agency may contact other persons or organizations to confirm the accuracy of my statement.
SIGNATURE
Date Signed
Print Name
Relationship to Applicant / Member
Identity Statement By completing this section, I attest to the identity of the individual named below.
Print Name Applicant / Member
Case or Social Security Number
By signing this statement I certify under penalty of perjury and false swearing that the information I have given is correct and complete to the best of my knowledge. I understand that the local agency may contact other persons or organizations to confirm the accuracy of my statement.
SIGNATURE
Date Signed
Print Name
Relationship to Applicant / Member
For agency use only I have determined, based on my contact with the applicant/member that s/he meets the definition of "Special Population" as described in Operations Memo 06-42, and is unable to provide any acceptable documentation. Therefore I am accepting this signed statement attesting to the citizenship and/or identity of the applicant/member in order to comply with the citizenship and identity documentation requirement.
SIGNATURE - Worker
Date signed
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