TABLE IV  -  Proof of U.S. Citizenship and Identification

Primary Documents

Explanation

***U.S. Passport

The Department of State issues this. A U.S. passport does not have to be currently valid to be accepted as evidence of U.S. citizenship, as long as it was originally issued without limitation.

Note: Spouses and children were sometimes included on one passport through 1980.  Consequently, the citizenship and identity of the included person can be established when one of these passports is presented.

 U.S. passports issued after 1980 show only one person

Exception: Do not accept any passport as evidence of U.S. citizenship when it was issued with a limitation. However, such a passport may be used as proof of identity.

***Certificate  of

Naturalization (N-550 or N-570)

Department of Homeland Security issues for naturalization.

Proof that a child was born to a mother on Medicaid in one of the 50 US States, District of Columbia or U.S. Territory

The proof may be in hard copy form from the state or territory itself, OR, a documented collateral contact with the state or territory.   Worker must complete an approved form documenting the collateral contact.  Documentation becomes part of the permanent verifications for the child's case record.

The documented collateral contact form must include:

• the state, name and phone number of the person contacted

• the child’s name and date of birth

• name, date and signature of worker making the call

***Documentation from Federally Recognized American Indian Tribes

Tribal Directory Information

Examples include: Tribal Enrollment Card and Certificate of Degree of Indian Blood

American Indian Card (I- 872) - DHS issues this card to identify member of the Texas Band of Kickapoos living near the U.S. Mexican border.  A classification code “KIC” and a statement on the back denote U.S. citizenship.

***Certificate of Citizenship

(N-560 or N-561)

Department of Homeland Security issues certificates of citizenship to individuals who derive citizenship through a parent.

Secondary Documents

Explanation

A U.S. public birth record showing birth in

one of the 50 U.S. States;

District of Columbia;

American Samoa;

Swain’s Island *Puerto Rico (if born on or after Jan.  13, 1941);

Virgin Islands of the U.S. (on or after Jan. 17, 1917);

Northern Mariana Islands (after  Nov. 4, 1986                       (NMI local time);

Or

Guam (on or after April 10, 1899)

The birth record document may be issued by the State, Commonwealth, territory or local jurisdiction. It must have been issued before the person was 5 years of age.

An amended birth record document that is amended after 5 years of age is considered fourth level evidence of citizenship.

Note: If the document shows the individual was born in Puerto Rico, the Virgin Islands of the U.S., or the Northern Mariana Islands before these areas became part of the U.S., the individual may be a collectively naturalized citizen. Collective naturalization occurred on certain dates listed for each of the territories.  *See additional requirements for Collective Naturalization.

***Certification of Report of Birth (DS-1350)

The Department of State issues a DS-l350 to U.S. citizens in the U.S. who were born outside the U.S. and acquired U.S. citizenship at birth, based on the information shown on the FS-240. When the birth was recorded as a Consular Report of Birth (FS-240), certified copies of the Certification of Report of Birth Abroad (DS-1350) can be issued by the Department of State in Washington, D.C.  The DS-1350 contains the same information as that on the current version of Consular Report of Birth FS-240. The DS-1350 is not issued outside the U.S.

***Consular Report of Birth Abroad of a Citizen of the United States of America (FS-240)

The Department of State consular office prepares and issues this. A Consular Report of Birth can be prepared only at an American Consular office overseas while the child is under the age of 18. Children born outside the U.S. to U.S. military personnel usually have one of these.

***Certification  of Birth Abroad (FS-545)

Before November 1, 1990, Department of State Consulates also issued Form FS-545 along with the prior version of the FS-240.  In 1990, U.S. Consulates ceased to issue Form FS-545. Treat an FS-545 the same as the DS-135O.

***Naturalization

SAVE (Systematic Alien Verification for Entitlements) interface through eFIND.

*** United States Citizen

Identification Card (I-197) or the prior version I-179 (Section 6036 referred to these documents in error as an I-97.)

INS issued the I-179 from 1960 until 1973. It revised the form and renumbered it as Form I-197. INS issued the I-197 from 1973 until April 7, 1983. INS issued Form I-179 and I-197 to naturalized U.S. citizens living near the Canadian or Mexican border who needed it for frequent border crossings. Although neither form is currently issued, either form that was previously issued is still valid.

Northern Mariana Card (I- 873)

The former Immigration and Naturalization Service (INS) issued the 1-873 to a collectively naturalized citizen of the U.S. who was born in the NMI before November 4, 1986. The card is no longer issued, but those previously issued are still valid.

Final adoption decree

The adoption decree must show the child’s name and U.S. place of birth. In situations where an adoption is not finalized and the State in which the child was born will not release a birth certificate prior to final adoption, a statement from a State approved adoption agency which shows the child’s name and U. S. place of birth is acceptable. The adoption agency must state in the certification that the source of the place of birth information is an original birth certificate.

Evidence of civil service employment by the U.S. government

The document must show employment by the U.S. government before June 1, 1976

Official Military record of service

The document must show a U.S. place of birth (for example a DD-214 or similar official document showing a U.S. place of birth)

Evidence of meeting the automatic criteria for U.S. citizenship outlined in the Child Citizenship Act of 2000

See Section 202-1 #4

Third Level  Documents

Explanation

Extract of hospital record on hospital letterhead established at the time of the person’s birth and was created at least 5 years before the initial application date and indicates a U.S. place of birth

Do not accept a souvenir “birth certificate” issued by the hospital.

Note: For children under 16 years of age, the document must have been created near the time of birth or 5 years before the date of application.

Life, Health or other Insurance record showing a U.S. place of birth and was created at least 5 years before the initial application date

Life or health 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.

Religious records recorded in the U.S. within 3 months of birth

Record must show the birth occurred in the U.S. and showing 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.

The school record must show the name of the child, the date of admission to the school, the date of birth, a U.S. place of birth and the name(s) and place(s) of birth of the applicant’s PARENTS.

Fourth Level Documents

Explanation

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 State 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 requires a fee.

Other document as listed in the explanation that was created at least 5 years before the application for Medicaid (or for children under age 16, near the time of birth)

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.

A delayed U.S. public birth record that was recorded more than 5 years after the person’s birth.

Statement signed by the physician or midwife who was in attendance at the time of birth.

Bureau of Indian Affairs Roll of Alaska Natives composed by the Secretary of the Interior in 1971 to verify citizenship.

Institutional admission papers from a nursing home, skilled nursing care facility or other institution and was created at least 5 years before the initial application date and indicates a U.S. place of birth

Admission papers generally 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.

Medical (clinic, doctor, hospital, or Indian Health Services (IHS)) record which was created at least 5 years before the initial application date and indicates a U.S. place of birth

Medical records generally 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: An Indian Health Services (IHS) face sheet is a medical record. It must be certified by IHS as being from their original records.

Note:   An immunization record is not considered a medical record for purposes of establishing U.S. citizenship.

Note:  For children under 16 the document must have been created near the time of birth or 5 years before the date of application.

Written Affidavit

Written affidavits may be used as 4th level evidence only in rare circumstances when the state is unable to secure evidence of citizenship from another, higher-level listing.  The affidavits must be supplied by the applicant or recipient and at least two additional individuals, one of whom is not related to the applicant or recipient.  Each of the two additional individuals must attest to having personal knowledge of the event(s) establishing the applicant’s or recipient’s claim of citizenship.  The individuals providing supporting affidavits must be able to prove their own citizenship and identity for the affidavit to be accepted.  

The applicant/recipient also submits an affidavit explaining why other documentary evidence is not available.

The affidavits must be signed under penalty of perjury.

Documents to Establish Identify

Explanation

***Any identity document described in section 274A(b) (1) (D) of the Immigration and Nationality Act

This section includes the following acceptable documents for Medicaid purposes:

Driver’s license issued by State or Territory either with a photograph of the individual or other identifying information of the individual such as name, age, sex, race, height, weight or eye color.

School identification card with a photograph of the individual.

U.S. military card or draft record.

Identification card issued by the Federal, State, or local government with the same information included on driver’s licenses.

Military dependent’s identification card.

U.S. Coast Guard Merchant Mariner card.

Note:

For children under 16: Affidavits of Identity may be used IF the following are not available:  school records,  report cards, nursery or day care records, clinic, doctor or hospital records.    

For children ages 16 and 17: Affidavits of Identity may be used IF the following are not available: when a school ID card with a photograph or driver's license are not available to an individual before the age of 18 OR when a driver's license, state ID or school photo ID is unattainable for some reason.   

An affidavit is only acceptable if it is signed under penalty of perjury by a parent or guardian stating the date and place of birth of the child and cannot be used if an affidavit for citizenship was provided.  Affidavits need not be notarized. States will be permitted to accept affidavits establishing the identity of children up to age 18.

Exception:  Do not accept a voter’s registration card.

Corroborating documents

At state option, 3 or more corroborating documents such as marriage licenses, divorce decrees, high school diplomas and employer ID cards to verify the identity of an individual.  Only to be used if applicant submitted 2nd or 3rd tier –not 4th tier-citizenship documentation.

Identity affidavit for some disabled individuals

Disabled individuals in residential care facilities may have their identity attested to by the facility director or administrator when the individual does not have or cannot get any documents on the preceding Identity list.    The affidavit is signed under penalty of perjury, but need not be notarized.