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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

U.S. Immigrations Category U.S. Immigrations Documents Document Comments

• Derivative T visa: T-2, T-3, T-4, T-5 or T-6 visa

• The of entry for benefits and services is the date of admission stamped on that individual’s passport or I-94 Arrival Record • Family member of a Victim of a Severe Form of • Persons with derivative T visas do not receive and are not required Trafficking: to present a Certification Letter or Eligibility Letter to demonstrate • Family Member enters the United States on the basis eligibility for benefits or services of a derivative T Visa • “Memo of Agreement” with Migration and Refugee Services ****The information below pertains to individuals Paroled as Refugee or Asylee, Pending Asylum Application or Individual in Removal Proceedings

If Born In Cuba: • Expired or unexpired Cuban passport that lists the holder's place of birth as being Cuba; or • Cuban birth certificate issued by the appropriate civil registry in Cuba If Born Outside Cuba: • Unexpired Cuban passport; • Nationality Certificate or • Citizenship Letter

Note: A Cuban consular certificate documenting an individual's birth outside of Cuba to at least one Cuban parent is not sufficient evidence to establish Cuban citizenship. This is true even if the consular certificate states that the individual to whom the certificate was issued is a Cuban citizen.

Note: A Cuban birth certificate acknowledging a birth outside of Cuba or Cuban consular birth record issued for a principal applicant who was not born in Cuba is not sufficient to prove Cuban citizenship. A birth certificate issued by an entity outside of Cuba is not sufficient evidence to establish Cuban citizenship. If Born In Haiti: • Expired or unexpired Haitian passport; • National Identity Card (also known as a Voting Card); • Birth certificate with photo identification; or • Birth Extract Issued by Haitian National Archives accompanied by photo identification If Born Outside Haiti: • Unexpired Haitian passport; • National Identity Card (also known as a Voting Card); or • Certificate of naturalization or certificate of citizenship issued by the Haitian government accompanied by photo identification