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REV. MAY 3, 2018 NEBRASKA DEPARTMENT OF MEDICAID ELIGIBILITY MANUAL LETTER #43-2018 HEALTH AND HUMAN SERVICES 477-000-003

If none of the above is available, you must have one document from the Citizenship listing and one document from the Identity listing below.

Citizenship (secondary list start at top) Identity (start at top)

A U.S. public birth record showing birth in:  One of the 50 U.S. States or Nebraska DHHS IM-22 proof of birth  District of Columbia  American Samoa  Swain’s Island  Puerto Rico (if born on or after 1-12-1941)  Virgin Islands of the U.S. (on or after 1-17- 1971)  Northern Mariana Islands (after 11-4- 1986)  Guam (on or after 4-10-1899)

Any of the following identity documents in the Immigration and Nationality Act:  Driver’s license issued by a U.S. State or Territory either with a photograph of the individual or other identifying information such as name, age, sex, race, height, weight or eye color  School identification card with a photograph of the individual  U.S. military card or draft record  Identification card issued by the Federal, State, or local government with the same information included on driver’s licenses such as name, age, sex, race, height, weight, or eye color  Military dependent’s identification card  Native American Tribal document  U.S. Coast Guard Merchant Mariner card

Note: For children under 16, school records may include nursery or daycare records. If none of the above documents in the preceding charts are available, an affidavit may be used. An affidavit is only acceptable if it is signed under penalty of perjury by a parent or guardian stating the date and place of the birth of the child and cannot be used if an affidavit for citizenship was provided. The parent’s signature on the DHHS application for assistance meets the requirement for this affidavit. Certification of Report of Birth (DS-1350) issued by Department of State if born outside the U.S. School record that shows date and place of birth and parent(s) name.

Consular Report of Birth Abroad of a Citizen of the United States of America (FS-240) Clinic, doctor or hospital record showing date of birth Certification of Birth Abroad (FS-545 or DS- 1350) Daycare or nursery school record showing date and place of birth United States Citizen Identification Card (I- 197) or the prior version I-179

Religious record (cradle roll, naming certificate, baptismal record, Amish or Mennonite bishop’s letter) Northern Mariana Card (I-873)

Life/health insurance policy for the child showing in addition to the child’s name, the child’s age or date of birth