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UPDATED: NOVEMBER 2009

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DOCUMENTS ESTABLISHING U.S. CITIZENSHIP AND IDENTITY continued Ver: 11/19/07

THIRD LEVEL DOCUMENTS (continued) Third Level documents continued Explanation: Satisfactory reliability when a primary or secondary document is not available; also requires an identity document Life, health or other insurance record showing a U.S. place of birth that was created at least 5 years before the initial application date Life, health or other insurance records may show biographical information for the person including place of birth; the record can be used to establish U.S. citizenship when it shows a U.S. place of birth.

Note: For children under 16, the document must have been created near the time of birth or 5 years before the date of application. Religious record recorded in the U.S. within 3 months of birth showing a U.S. place of birth Religious record recorded in the U.S. within 3 months of birth showing a U.S. place of birth and either the date of birth or the individual’s age at the time the record was made. The record must be an official record recorded with the religious organization. Entries in a family bible are not considered religious records. Early school record showing U.S. place of birth Early school record showing date of admission, a U.S. place and date of birth and names and places of birth of the applicant’s parents. School records must be verified with the school’s administration.

FOURTH LEVEL DOCUMENTS Fourth Level Documents Explanation: Satisfactory reliability when a primary, secondary or third level document is not available; should be used only in the rarest of circumstances; also requires an identity document. Federal or State census record showing U.S. citizenship or a U.S. place of birth (Generally for persons born 1900 through 1950) The census record must also show the applicant’s age. Note: Census records from 1900 through 1950 contain certain citizenship information. To secure this information the applicant, recipient or social services district should complete a Form BC-600, Application for Search of Census Records for Proof of Age. Add in the remarks portion “U.S. citizenship data requested.” Also add that the purpose is for Medicaid eligibility. This form also requires a fee. Other documents as listed in the explanation column that were created at least 5 years before the application for Medicaid (For children younger than 16, near the time of birth or 5 years before the application) This document must be one of the following and show a U.S. place of birth: • Seneca Indian tribal census record; • Bureau of Indian affairs tribal census records of the Navajo Indians; • U.S. State Vital Statistics official notification of birth registration; • Delayed U.S. public birth record that was recorded more than 5 years after the person’s birth; • Statement signed by the physician/midwife who was in attendance at the time of birth; or • Bureau of Indian Affairs Roll of Alaska Natives.

(MRG)