Special Assistance SA3240f2

(County Letterhead)

Figure 2 - U. S. CITIZENSHIP DOCUMENTATION BIRTH CERTIFICATE REQUEST

(Date)

Re:

County Case No.:

The individual named above has applied for Special Assistance or is a current recipient being evaluated for continuing Special Assistance eligibility. We are attempting to document his/her U. S. citizenship per section 6036 of the 2005 Federal Reduction Act mandate. Please send us a certified birth certificate at your earliest convenience so that the application/redetermination can be processed. The needed authorization and information is provided below.

I, ____________________________, authorize _________________ County Department of Social Services to obtain a certified birth certificate on my behalf.

_________________________________________

Signature

I am the legal guardian for the above named individual and I authorize ____________________________

County Department of Social Services to obtain a certified birth certificate for the above named individual. [NOTE: A copy of the Legal Guardianship papers must accompany this request.]

_________________________________________

Signature

Date signed: ____________________________________

Full Name you believe is on the Certificate: ______________________________________________________

Date of Birth: _______________________ County of Birth: _

Father's Full Name:

Mother's Full Maiden Name: ___

County Making Request: ____________________________________ Please mail the birth certificate to:

Thank you for your assistance.

Sincerely, (Contact/address for county)

Income Maintenance Caseworker

Phone: _______________________________