Learn about the Medicaid 1115 Transformation Waiver Renewal.
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Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
To provide documentation of
- citizenship, either by birth or naturalization, for an individual of any age.
- identity for a child under age 16.
- identity for a disabled individual in a residential care facility.
When to Prepare
The affidavit is to be used as a last resort when the Medicaid applicant or recipient is unable to provide other documentation of citizenship or identity.
Note:The affiant is the individual certifying the facts contained in the affidavit.
When used to document citizenship:
- The affidavit must be completed by two adults, regardless of their relationship to the Medicaidapplicant/recipient.
- The affiant must complete all the blanks in Part A.
- The applicant/recipient (parent/guardian if for a child under age 18) or applicant/recipient'sauthorized representative must complete all the blanks in Part B.
When used to document identity for a child under age 16, the parent or guardian of the child must complete all the blanks in Part A, except for the section addressing why the applicant is unable to produce documentary evidence of citizenship. Completion of Part B is not required.
When used to document identity for a disabled individual in a residential care facility, the facility director or administrator must attest to identity of the individual.