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State of Maryland Medical Assistance Manual Revised July 2012

Attachment B-Affidavit of Citizenship

State of Maryland

Department of Health and Mental Hygiene

AFFIDAVIT OF CITIZENSHIP

This Document Is Not Valid Unless Fully Completed.

1. My name is _________________________, and I live at _________________________ _______________________________________________________________________. � I am a U.S. citizen. � I am 18 years old or older.

2. Are you a relative of the individual named above? �

�

3. How long have you known this individual? __________________________ How do you know this individual? _________________________________________

4. How do you know the facts you present in this Affidavit? _______________________________________________________________________

5. I have personal knowledge of how the applicant/recipient became a U.S. citizen. The facts known to me are that he/she was: �

�

� ____________________________________________________________________ �

6. The individual is 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 (7/1/06)

Applicant/Recipient Name: _____________________________Date of Birth: _________

Address:___________________________________________________________________________ ________________

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

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