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State of Maryland Medical Assistance Manual Revised July 2012

Attachment A-Affidavit of Citizenship (A/R) Only

State of Maryland Department of Health and Mental Hygiene AFFIDAVIT OF CITIZENSHIP To Be Completed By Applicant/Recipient Only This Document Is Not Valid Unless Fully Completed.

1. � I am a U.S. citizen.

2. � I am 18 years old or older.

3. I am a U. S. Citizen because: � I was born in the U.S. or a U.S. territory. Date and place:__________________________ � I was naturalized as a U.S. citizen. Date and place:_______________________________ � I was born overseas to a U.S. citizen parent(s). Date, place, and parent(s) name: _____________________________________________ � Other: __________________________________________________________________

4. I am unable to produce documents to prove citizenship because: __________________________________________________________________________ __________________________________________________________________________

I affirm and declare under penalty of perjury that the facts I state in this Affidavit are true, correct, and complete to the best of my ability, belief, and knowledge.

Signature

Printed Name

Date Signed DES/AF2 (7/1/

Applicant/Recipient Name: ____________________________Date of Birth: __________

Address: ______________________________________________________________________

Head of Household (if the individual is younger than 21 years old):