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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL APPENDIX I NON-CITIZEN DOCUMENTATION MATRIX Division of Welfare and Supportive Services Medical Assistance Manual 23 Jan 05 MTL 01/23

NON-CITIZEN DOCUMENTATION MATRIX

U.S. Immigrations Category U.S. Immigrations Documents Document Comments Paroled as Cuban Haitian Entrant (CHE) – Status • Form I-94, Arrival/Departure Record, with a Dept. of • U.S. immigration documentation is evidence of nationality. No additional Pending Homeland Security or legacy Immigration and Naturalization evidence of nationality is required. Service stamp noting “Cuban0Haitian Entrant (status Pending).” Paroled as a Refugee or Asylee • Form I-94 or Cuban or Haitian passport with a Dept. of • To be eligible under this provision, the I-94 must note that the individual is a  Acceptable documents for individuals paroled Homeland and Naturalization Service stamp noting “parole refugee or asylee as refugees or asylees under 212(d)(5) under 212(d)(5).” *

• Form I-766, Employment Authorization Document (EAD), • NONE with category code “C11” or “ao4”. The C11 code indicates that the individual was paroled into the United States.

*Documentation issued by U.S. Immigration and Customs • ****See Passport and/or Birth Certificate requirements listed at the end of the Enforcement (ICE), such as Form I-830m Notice to EOIR: document Alien Address containing information that the individual was released from ICE custody and paroled pursuant to 8 C.F.R 212.5 • “Memo of Agreement” with Migration and Refugee Services Pending Asylum Application • An EAD with a category code of “C08”. The C08 code • ****See Passport and/or Birth Certificate requirements listed at the end of the  Acceptable documents for individuals who indicates that the individual has a pending application for document have applied for Asylum but are still pending asylum. a decision • Form I797C, Notice of Action confirming USCIS receipt of the individual’s Application for Asylum and Withholding of Removal, Form I-589 Individual in Removal Proceedings • Documentation issued by the Department of Homeland • ****See Passport and/or Birth Certificate requirements listed at the end of the  Acceptable documents for Individuals in Security (DHS) or the Department of Justice (DOJ) document Removal Proceedings Executive Office for Immigration Review (EOIR) showing pending removal proceeding, such as Notice to Appear, DHS Form Refugees • I-94 Arrival/departure record noting that the individual has • Notations may include references to employment authorization, indefinite  Acceptable documents for refugees admitted been admitted under 207 of the INA status, and the requirement to obtain permission before leaving the United under 207 of the INA (Immigration and • RE-1 admission code on the I-94 States. Nationality Act) • RE-2 admission code on the I-94 • Principal Refugee • RE-3 admission code on the I-94 • Spouse of Principal Refugee • RE-4 admission code on the I-94 • Child of Principal Refugee

• Collateral relatives of a Principal Refugee (siblings, nieces, nephews, • RE-5 admission code on the I-94 cousins etc.) • 1-766 Employment Authorization Document with the code • Certain Haitian refugees A03 • NONE • DHS form I571