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Medical Services – Appendix C, Verification of Citizenship, Alien Status and SSN Enumeration Revised (05/18) Deferred Action Status • USDHS Form I-797 indicating a notice of action for Deferred Action. • USDHS Form I-765, Application for Employment Authorization or receipt from USCIS indicating filing of application. • USDHS Form I-766, Employment Authorization Document. • Any verification from the immigration authorities or other authoritative documents indicating Deferred Action Status. Eligible and exempted from the 5 year bar except noncitizens granted deferred action under the Deferred Action for Childhood Arrivals (DACA) process are not considered lawfully present and is not eligible for Medicaid. Administrative Stay of Removal • USDHS Form I-246, Stay of Removal. • Any verification from the immigration authorities or other authoritative documents indicating Administrative Stay of Removal. Eligible and exempted from the 5 year bar. VISA with Adjustment of Status • USDHS Form I-94, Arrival/Departure Record. • USDHS Form I-485, Application to Register Permanent Residence or Adjust Status. • Any verification from the immigration authorities or other authoritative documents indicating VISA with Adjustment of Status. Eligible and exempted from the 5 year bar. Asylum and for Withholding of Removal • USDHS Form I-589, Application for Asylum and Withholding, filed. • USDHS Form I-765, Application for Employment Authorization, filed. • USDHS Form I-766, Employment Authorization Document Eligible and exempted from the 5 year bar. Withholding of Removal under the Convention Against Torture • USDHS Form I-589, Application for Asylum and for Withholding of Removal. • Any verification from the immigration authorities or other authoritative documents indicating Withholding of Removal under the Convention Against Torture. Eligible and exempted from the 5 year bar. Special Immigrant Juvenile • USDHS Form I-360, Petition for Amerasian, Widow(er), or Special Immigrant. • Any verification from the immigration authorities or other authoritative documents indicating Special Immigrant Juvenile. Eligible and exempted from the 5 year bar. Victim of Severe Trafficking • USDHS Form I-914, Application for T-Nonimmigrant Status. • USDHS Form I-918, Petition for U-Nonimmigrant Status. • Any verification from the immigration authorities or other authoritative documents indicating Victim of Severe Trafficking. Eligible and exempted from the 5 year bar. V. Social Security Number (SSN) Enumeration