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Page 3 of 6 § 10:72-3.2 Citizenship 12. Certain aliens who are victims of domestic violence as specified in (b)12 above, but only after the alien has been present in the United States for five years. (d) Persons claiming to be citizens and eligible aliens shall provide the county social service agency with documentation of citizenship or alien status. (e) As a condition of eligibility, all applicants for Medicaid (except for those applying solely for services related to the treatment of an emergency medical condition) shall sign a declaration under penalty of perjury that they are a citizen of the United States or an alien in a satisfactory immigration status. In the case of a child or incompetent applicant, another individual on the applicant's behalf shall complete the same written declaration under penalty of perjury. 1. The following shall be acceptable documentation of United States citizenship: i. A birth certificate; ii. A religious record of birth recorded in the United States or its territories within three months of birth. The document must show either the date of birth or the individual's age at the time the record was created; iii. A United States passport (not including limited passports which are issued for periods of less than five years); iv. A Report of Birth Abroad of a Citizen of the U.S. (Form FS-240); v. A U.S. Citizen I.D. Card (INS Form-197), Naturalization Certificate (INS Form N-550 or N-570); vi. A Certificate of Citizenship (INS Form N-560 or N-561); vii. A Northern Mariana Identification Card (issued by the INS to a collectively naturalized citizen of the United States who was born in the United States before November 3, 1986); viii. An American Indian Card with a classification code "KIC" (issued by the INS to identify U.S. citizen members of the Texas Band of Kickapoos); or ix. A contemporaneous hospital record of birth in one of the 50 states, the District of Columbia, Puerto Rico (on or after January 13, 1941), Guam (on or after April 10, 1899), the U.S. Virgin Islands (on or after January 17, 1917), American Samoa, Swain's Island, or the Northern Mariana Islands (unless the person was born to foreign diplomats residing in any of these jurisdictions). 2. If an applicant presents an expired INS document or is unable to present any document demonstrating his or her immigration status, the county social service agency shall refer the applicant to the local INS district office to obtain evidence of status. If, however, the applicant provides an alien registration number, but no documentation, the county social service agency shall file INS Form G-845 along with the alien registration number with the local INS district office to verify status. 3. The following sets forth acceptable documentation for eligible aliens: i. Lawful Permanent Resident--INS Form I-551, or for recent arrivals, a temporary I-551 stamp in a foreign passport or on Form I-94. ii. Refugee--INS Form I-94 annotated with stamp showing entry as refugee under section 207 of the Immigration and Nationality Act and date of entry into the United States; INS Form I-688B annotated "274a. 12(a)(3)," I-766 annotated "A3," or I-571. Refugees usually adjust to Lawful Permanent Resident status after 12 months in the United States, but for purposes of determining Medicaid eligibility they are considered refugees. Refugees whose status has been adjusted will have INS Form I-551 annotated "RE-6," "RE-7," "RE-8," or "RE-9." iii. Asylees--INS Form I-94 annotated with a stamp showing grant of asylum under section 208 of the Immigration and Nationality Act, a grant letter from the Asylum Office of the Immigration and Naturalization Service, Forms 688B annotated "274a. 12(a)(5)," or I-766 annotated "A5."