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

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL

U.S. Immigrations Category U.S. Immigrations Documents Document Comments Lawful Permanent Residents • Form I-551 Permanent Resident Card (or Resident

 Acceptable documents for lawful permanent Alien Card) with the following codes:

residents who previously held one of the  RE6 above identified statuses.  RE7 • Adjusted Principal Refugee  Note that this DOES NOT refer to  RE8 • Spouse of Principal Refugee Amerasians or Iraqi and Afghan  RE9 • Child of Principal Refugee Special Immigrants, who are admitted  AS6 • Collateral Relatives of Principal Refugee as lawful permanent residents.  AS7 • Adjusted Principal Asylee  AS8 • Spouse of principal Asylee  CH6 • Child of Principal Asylee  HA6 • Adjusted Cuban/Haitian Entrant (Status Pending)  HB6 • Adjusted Cuban/Haitian Entrant (Haitian national who had applied for

asylum)  GA6

• Adjusted Cuban/Haitian Entrant (Haitian national who had been  GA7 paroled)  GA8 • Adjusted Iraqi asylee  ST6 • Souse of GA6  ST7 • Child of GA6  ST8 • Victim of a Severe Form of Trafficking  ST0 • Spouse of a ST6  ST9 • Parent of a Victim of a ST6

• Sibling of a Victim of a ST6 • Foreign Passport with unexpired, temporary I-551

stamp and the following codes:  RE6

 RE7 • Adjusted Principal Refugee  RE8 • Spouse of Principal Refugee  RE9 • Child of Principal Refugee  AS6 • Collateral Relatives of Principal Refugee  AS7 • Adjusted Principal Asylee  AS8 • Spouse of Principal Asylee

• •

Child of Principal Asylee

Employment Authorization Documents:  Form I-766 Employment Authorization Document with the code A10  Note: this code only confirms eligibility for Cuban or Haitian nationals. Iraqi & Afghan Special Immigrants • Principal Applicant Iraqi or Afghan Special Immigrant • Iraqi or Afghan passport with an immigrant visa stamp noting that  Acceptable documents for Iraqi & Afghan

the individual has been classified under IV (Immigrant Visa) Special Immigrants

Category SI1 or SQ1 and DHS stamp or notation on passport or I-94 showing date of admission • Spouse of Principal Applicant Iraqi or Afghan Special • Iraqi or Afghan passport with an immigrant visa stamp noting that Immigrant the individual has been classified under IV (Immigrant Visa)

Category SI2 or SQ2 and DHS stamp or notation on passport of I-94

showing date of admission • •

Iraqi or Afghan passport with an immigrant visa stamp noting that

Unmarried Child Under 21 Years of Age of Iraqi or the individual has been classified under IV (Immigrant Visa) Afghan Special Immigrant Category SI3 or SQ3 and DHS stamp or notation on passport of I-94 showing date of admission • DHS Form I-551 (“green card”) with an IV (immigrant visa) code for