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8 The following “last resort” documents are to be used rarely and only when the more reliable sources listed previously are not available or cannot reasonably be obtained. Please note that this would not include situations where the individual is unwilling to pay the cost of ordering a birth certificate. • A Seneca Indian tribal census record showing a U.S. place of birth, which was created at least 5 years before the application for Medicaid • A Bureau of Indian Affairs tribal census record of the Navajo Indians, showing a U.S. place of birth, which was created at least five years before the application for Medicaid • A U.S. State Vital Statistics official notification of birth registration showing a U.S. place of birth, which was created at least five years before the application for Medicaid • A statement signed by the physician or midwife who attended the birth, showing a U.S. place of birth, which was created at least 5 years before the application for Medicaid • Institutional admission papers from a nursing facility or other institution showing a U.S. place of birth • Clinic, doctor, or hospital records created at least five years before the application for Medicaid that indicate a U.S. place of birth. For children under sixteen, the document must have been created near the time of birth, or five years before the application for Medicaid • A religious record (recorded by a religious organization) in the U.S. created within three months of the individual’s birth. Please note that entries in a family’s personal religious text are not considered to be religious records for the purpose of citizenship verification • Early school records showing a U.S. place of birth • A special affidavit signed, State Form 53691, under penalty of perjury, by two individuals (other than the applicant/recipient) who have personal knowledge of the event establishing the person’s citizenship status. At least one of the individuals must be unrelated to the applicant/recipient and both must prove their own citizenship.

As stated previously, when secondary documentation is used, the individual’s identity must also be verified. Sources of identity documentation include: • A driver’s license with picture or other identifying information • A school picture ID • Nursery or day care records for a child not yet in school • A U.S. military card or draft record • State, federal, or local government ID containing information identical to that on a driver’s license • A military dependent’s ID card • A U.S. Coast Guard Merchant Mariner card