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Accept any of the documents listed in Chart 4 as fourth level evidence of US citizenship if the document meets the criteria listed under “Explanations and Notes”, the applicant alleges birth in the US, and there is nothing indicating the person is not a US citizen (e.g. lost US citizenship). In addition, a second document establishing identity must be presented. Fourth level evidence, as described below, consists of documents established for a reason other than to establish US citizenship and to show a US place of birth. The place of birth on the document and the application must agree. The written affidavit described in this chart may be used only when the State is unable to secure evidence of citizenship listed in any other chart. Chart 4 – Fourth Level Evidence of Citizenship Fourth Level Documents Explanations and Notes on Documentation Federal or State census record showing US citizenship or a US place of birth (Generally for persons born 1900 through 1950). The census record must also show the applicant’s age. Note: Census records from 1900 through 1950 contain certain citizenship information. To secure this information the applicant, recipient or State should complete a Form BC-600, Application for Search of Census Records for Proof Age. Add in the remarks portion “US citizenship data requested.” Also, add that the purpose is for Medicaid eligibility. This form requires a fee. Other documentation as listed in the explanation that was created at least 5 years before the application for Medicaid This document must be one of the following and show a US place of birth: • Seneca Indian tribal census record • Bureau of Indian Affairs tribal census records of the Navaho Indians • US State Vital Statistics official notification of birth registration • An amended US public birth record that is amended more than 5 years after the person’s birth • Statement signed by the physician or midwife who was in attendance at the time of birth. Institutional admission papers from a nursing home, skilled nursing care facility or other institution and was created at least 5 years before the initial application date and indicates a US place of birth Admission papers generally show biographical information for the person including place of birth; the record can be used to establish US citizenship when it shows a US place of birth. Medical (clinic, doctor, or hospital) record and was created at least 5 years before the initial application date and indicates a US place of birth Medical records generally show biographical information for the person including place of birth; the record can be used to establish US citizenship when it shows a US place of birth. Note: An immunization record is not considered a medical record for purposes of establishing US citizenship. Note: For children under 16 the document must have been created near the time of birth or 5 years before the date of application. Written Affidavits Affidavits should ONLY be used in rare circumstances. If the documentation requirement needs to be met through affidavits,