Page 4

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

U.S. Immigrations Category U.S. Immigrations Documents Document Comments Cuban & Haitian Entrants III • DHS Form I-221 • Order to Show Cause and Notice of Hearing  A national of Cuba or Haiti who is the • DHS Form I-862 • Notice to Appear subject of removal, deportation or • DHS Form I-220A • Order of Release on Recognizance exclusion proceedings under the INA and • DHS Form I-122 • Notice to Applicant Detained for a Hearing Before an Immigration with respect to whom a final, non-

Judge appealable, and legally enforceable order • DHS Form I-221S • Order to Show Cause, Notice of Hearing and Warrant for Arrest of removal, deportation or exclusion has

not been entered

• Application for Asylum and Withholding of Removal; Individual is • Copy of DHS Form I-589 date stamped by the subject of removal, exclusion or deportation proceedings. Executive Office for Immigration Review (EOIR) • Application to Register Permanent Residence or to Adjust Status; • Copy of DHS Form I-485 date stamped EOIR Individual is subject of removal, exclusion or deportation proceedings.

• Notice of Appeal from a Decision of an Immigration Judge, date • EOIR-26 stamped by the Board of Immigration Appeals

• Application for suspension of deportation/cancellation of removal submitted to DHS or EOIR • I-766 Employment Authorization Document with the • NONE code C10

• Other applications for relief that have been date • Example: a notice of a hearing date before an Immigration Judge or a stamped EIOR case appeal filing receipt from the Board of Immigration Appeals • Other documentation pertaining to an applicant’s removal, exclusion or deportation proceedings • “Memo of Agreement” with Migration and Refugee Services Cuban & Haitians Entrants IV • USCIS receipt for filing Form I-589 • Application for Asylum and Withholding of Removal  A national of Cuba or Haiti who has an • I-766 Employment Authorization document with the • NONE application for asylum pending with the code C08 DHS/USCIS or with an EOIR Immigration • “Memo of Agreement” with Migration and Refugee Court or the Board of Immigration Appeals Services and with respect to whom a final, non- appealable, and legally enforceable order of removal, deportation or exclusion has not been entered. Amerasians • AM-1 admission code on the I-94 • Amerasian born in Vietnam after Jan. 1, 1962, and before Jan. 1, 1976, who  Acceptable documents for certain Amerasians was fathered by a U.S. citizen (certain Amerasians from Vietnam who are • AM-2 admission code on the I-94 • Spouse or child of Amerasian admitted to the United States as immigrants • AM-3 admission code on the I-94 • Mother, guardian or next-of-kin of Amerasian pursuant to 584 of the Foreign Operations, • AM-6 adjustment code on Form I-551 • Permanent Resident Card (or Resident Alien Card) of Amerasian Export Financing, and Related Programs

• Permanent Resident Card (or Resident Alien Card) Spouse or child of Appropriations Act, 1988 of Public Law) • AM-7 adjustment code on Form I-551 Amerasian

• Permanent Resident Card (or Resident Alien Card) of Mother, guardian or • AM-8 adjustment code on Form I-551 next-of-kin of Amerasian

• “Laissez Passer”; may have temporary I-551 stamp • Vietnamese Exit Visa with codes AM-1, AM-2 or AM-3 • Vietnamese passport with codes AM-1, AM-2, AM-3 • May have temporary I-551 stamp • United States passport with codes AM-1, AM-2 or AM- 3 • NONE • “Memo of Agreement” with Migration and Refugee Services