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File Size: 116.2 kB
Pages: 1
Date: December 11, 2008
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHCAA-BOC
Word Count: 351 Words, 2,198 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/F1/F10161.pdf

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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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