Sworn Statement Form For Medi-cal
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Make edits, fill in missing information, and update formatting in US Legal Forms—just like you would in MS Word.
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If this form requires notarization, complete it online through a secure video call—no need to meet a notary in person or wait for an appointment.
We protect your documents and personal data by following strict security and privacy standards.
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FAQ
If you are requesting an authorized copy of a birth, death, or marriage certificate, you MUST complete the Sworn Statement included with the application and sign the statement (declaring under penalty of perjury that you are entitled by law to receive an authorized copy). Your Sworn Statement must be notarized.
A sworn statement is a written statement of fact related to a legal proceeding. It is signed by the declarant to state that all the content is true, and that they acknowledge that the penalty of perjury may follow if they do not tell the truth.
A sworn declaration (also called a sworn statement or a statement under penalty of perjury) is a document that recites facts pertinent to a legal proceeding. It is very similar to an affidavit but is not witnessed and sealed by an official such as a notary public.
1. Give proof that you are a resident of California, when you are asked for it. 2. Declare your citizenship or immigration status, when you are applying for Medi-Cal.
Documents to Confirm Eligibility Social Security Number. Identity. Citizenship. Immigration Status. Income. Not Incarcerated. Minimum Essential Coverage. American Indian or Alaskan Native.