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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 October 2013 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 1 3

• Medical records, including but not limited to, hospital, clinic or doctor records or admission papers from a nursing facility, skilled care facility or other institution that indicate a U.S. place of birth • Life, health or other insurance records that indicate a U.S. place of birth • Official religious record recorded in the U.S. indicating a U.S. birth • School records, including pre-school, Head Start and day care, showing child’s name and U.S. place of birth • Federal or state census records showing U.S. citizenship or U.S. place of birth • Certification of U.S. birth • A Certification of Report of Birth, issued to U.S. citizens who were born outside the U.S. • A report of Birth Abroad of a U.S. citizen b. Affidavit If no other documentation exists, the individual may submit an affidavit signed, under penalty of perjury, by another person who can reasonably attest to the applicant’s identity. Such affidavit must contact the applicant’s name and other identifying information. The affidavit does not have to be notarized. C. Agency Actions 1. Documen- tation From Case Record and Individual Documentation of citizenship and/or identity may be obtained from a number of different sources, including the sources listed below. Photocopies of original documents are acceptable. • Existing LDSS agency records, as long as the documentation conforms to Medicaid policy for citizenship and identity verification in M0220 of the Medicaid Eligibility Manual. • A federal agency or another State agency. A verification of citizenship made by a federal or state agency is acceptable, as long as the verification was done on or after July 1, 2006. No further documentation of citizenship or identity is required.