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MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |32 Effective Date: January 2019 than to establish U. S. citizenship and showing a U. S. place of birth. The U. S. place of birth on the document and documented place of birth on the application must agree. The written affidavit may be used only when the specialist is unable to secure evidence of citizenship in any other chart. Fourth Level Documents Explanation Federal or State census record showing U.S. citizenship or a 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, beneficiary, or State should complete a Form BC-600, Application for Search of Census Records for Proof of Age. ADD in the remarks portion “U.S. citizenship data requested.” Also, add that the purpose is for Medicaid eligibility. This form requires a fee. Written Affidavit An affidavit signed by another individual under penalty of perjury who can reasonably attest to the applicant’s citizenship can be submitted with the applicant’s name, date of birth and place of U.S. birth. The affidavit does not have to be notarized. Citizenship Addendum Explanation If the document used to verify U. S. citizenship indicates the individual was born in Puerto Rico, the Virgin Islands of the U.S. or the Northern Marinara Islands before these areas became part of the U.S. the individual may Puerto Rico: Evidence of birth in Puerto Rico on or after April 11, 1899, and the applicant/beneficiary’s statement that he or she was residing in the U.S. possession or Puerto Rico on January 13, 1941; or Evidence that the applicant/beneficiary was a Puerto Rican citizen and the applicant/beneficiary’s statement that he or she was residing in Puerto Rico on March 1, 1917, and that he or she did not take an oath of allegiance to Spain.