Form DHCS0010 "Affidavit of Identity for U.S. Citizen or National for Disabled Individuals Living in Institutional Care Facilities" - California

What Is Form DHCS0010?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2008;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHCS0010 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS0010 "Affidavit of Identity for U.S. Citizen or National for Disabled Individuals Living in Institutional Care Facilities" - California

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State of California – Health and Human Services Agency
Department of Health Care Services
Affidavit of Identity for U.S. Citizen or National For
Disabled Individuals Living in Institutional Care Facilities
To the institutional/residential facility director or
administrator:
Fill out and sign below.
Print neatly and submit to the county social services office.
Important!
All other means of verifying identity must be pursued
before submitting this affidavit to the county.
Identity of Disabled Individual
Name of individual
First
Middle
Last
Institutional/residential care director or administrator reads and signs below.
On behalf of the above individual, under penalty of perjury under California state law, I declare the identity of
the person named above.
_______________________________________________________
Date:____________________
S
ignature of institutional/residential facility director or administrator
________________________________________________________
Name of institutional/residential facility director or administrator (print)
________________________________________________________
Name of institutional/residential facility
Address ________________________________________________________________________________
City
State
Zip
____________________________________
______________________________________
e
l
Telephone
-mai
If you have questions, please contact the county social services office at:
County fills out this box
Case No:
Case Name:
DHCS 0010 (01/08)
Page 1 of 1
State of California – Health and Human Services Agency
Department of Health Care Services
Affidavit of Identity for U.S. Citizen or National For
Disabled Individuals Living in Institutional Care Facilities
To the institutional/residential facility director or
administrator:
Fill out and sign below.
Print neatly and submit to the county social services office.
Important!
All other means of verifying identity must be pursued
before submitting this affidavit to the county.
Identity of Disabled Individual
Name of individual
First
Middle
Last
Institutional/residential care director or administrator reads and signs below.
On behalf of the above individual, under penalty of perjury under California state law, I declare the identity of
the person named above.
_______________________________________________________
Date:____________________
S
ignature of institutional/residential facility director or administrator
________________________________________________________
Name of institutional/residential facility director or administrator (print)
________________________________________________________
Name of institutional/residential facility
Address ________________________________________________________________________________
City
State
Zip
____________________________________
______________________________________
e
l
Telephone
-mai
If you have questions, please contact the county social services office at:
County fills out this box
Case No:
Case Name:
DHCS 0010 (01/08)
Page 1 of 1