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Medical Services – Appendix C, Verification of Citizenship, Alien Status and SSN Enumeration Revised (05/18) • Medical (clinic, doctor, or hospital) record which was created at least 5 years before the initial application date and indicates a U.S. place of birth unless the application is for a child under 5. • Other document that was created at least five years before application for Medicaid. These documents are Seneca Indian tribal census record, Bureau of Indian Affairs tribal census records of the Navaho Indians, U.S. State Vital Statistics official notification of birth registration, an amended U.S. public birth record that is amended more than 5 years after the person’s birth or a statement signed by the physician or midwife who was in attendance at the time of birth. • The Roll of Alaska Natives maintained by the Bureau of Indian Affairs. • Written affidavit. This should be in rare circumstances when the applicant or recipient cannot provide evidence from another listing. Written affidavits may be used in circumstances when the state is unable to secure evidence of citizenship from another listing. The affidavits must be supplied by at least two individuals, one of whom is not related to the recipient. Each must attest to having a personal knowledge of the event(s) establishing the recipient’s claim of citizenship. Those making affidavits will be subject to prosecution for perjury. If the persons claiming knowledge of another’s citizenship has information, which explains why documentary evidence establishing the claim of citizenship does not exist or cannot be readily obtained, the affidavit should contain this information as well. A second affidavit from the recipient or other knowledgeable individual explaining why documentary evidence does not exist or cannot be readily obtained must also be requested. II. Identity If citizenship is verified with a document on the secondary or lower level listed above, providing proof of identity will be required. Acceptable forms of identity are: 1. Driver’s license issued by the State or Territory either with a photograph of the individual or other identifying information of the individual such as name, age, sex, race, height, weight or eye color. 2. Identification card issued by the Federal, State or local government with the same information included on driver’s licenses (e.g., ID card issued by DF&A). 3. School identification card with a photograph of the individual.