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State of Maryland Medical Assistance Manual Revised July 2012

Attachment C- Affidavit of Identity (Child Younger than 16 years Old)

State of Maryland Department of Health and Mental Hygiene AFFIDAVIT OF IDENTITY For a Child Younger Than 16 years Old This Document Is Not Valid Unless Fully Completed.

1. My name is ___________________________________, and I live at ___________________

_____________________________________________________________________________. 2. I am the child's: �Parent �Legal guardian �Other

3. I am unable to produce the required documents to prove the child's identity (U.S. passport, Certificate of Naturalization (N-550 or N-570), Certificate of Citizenship (N-560 or N-561), school photo ID card, school record with date and place of birth, nursery or day care record with date and place of birth, learner driver's license, or military dependent's ID card) 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/AF3(7/1/06)

Child’s Name: _________________________________________________ Child's Date of Birth: __________ Child's Age: _______ Child's Place of Birth: ____________________________________________ Child's Current Address:

_________________________________________________________