Department of Human Services: Chapter7

Secondary Documents to Establish US Citizenship (Chart 2)

Secondary evidence of citizenship is documentary evidence of satisfactory reliability that is used when primary evidence of citizenship is not available. In addition, a second document establishing identity MUST also be presented as described in Chart 5, Evidence of Identity.

Available evidence is evidence that exists and can be obtained during the normal application period of 45 days for AR/AX applicants/recipients or 90 days for SR/QM applicants/recipients.

Accept any of the documents listed in this Chart as secondary evidence of US citizenship if the document meets the criteria listed under “Explanations and Notes” and there is nothing indicating the person is not a US citizen (e.g. lost US citizenship).

Chart 2 – Secondary Evidence of Citizenship
Secondary Documents	Explanations and Notes on Documentation
A US public birth record showing birth in: one of the 50 US States; District of Columbia ; American Samoa Swain’s Island Puerto Rico (if born on or after January 13, 1941 ); Virgin Islands of the US (on or after January 17, 1917); *Northern Mariana Islands (after November 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 US , or the Northern Mariana Islands before these areas became part of the US, 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-1350 to US citizens in the US who were born outside the US and acquired US 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 US
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 US to US 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, US consulates ceased to issue Form FS-545. Treat an FS-545 the same as the DS-1350.
United States Citizen Identification Card (I-197) or the prior version (I-179)	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 US 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.
American Indian Card (I-872)	DHS issues this card to identify a member of the Texas Band of Kickapoos living near the US/Mexican border. A classification code “KIC” and a statement on the back denote US citizenship.
Northern Mariana Card (I-873)	INS issued the I-873 to a collectively naturalized citizen of the US who was born in the Northern Mariana Islands 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 US 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 that shows the child’s name and US 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 US government	The document must show employment by the US government before June 1, 1976.
Official Military record of service	The document must show a US place of birth (for example a DD-214 or similar official document showing a US place of birth).

Third Level Documents to Establish US Citizenship (Chart 3)

Third level evidence of US citizenship is documentary evidence of satisfactory reliability that is used when neither primary nor secondary evidence of citizenship is available. Third level evidence may be used ONLY when primary evidence can not be obtained within 45 days for AR/AX or 90 days for SR/QM, secondary evidence does not exist or cannot be obtained, and the applicant or recipient alleges being born in the US In addition, a second document establishing identity MUST be presented as described in Chart 5, Evidence of Identity.

Accept any of the documents listed in Chart 3 as third level evidence of US citizenship if the document meets the criteria listed under “Explanations and Notes”, the applicant alleges birth in the US, and there is nothing indicating the person is not a US citizen (e.g. lost US citizenship).

Third level evidence is generally a non-government document established for a reason other than to establish US citizenship and showing a US place of birth. The place of birth on the non-government document and the Medicaid application must agree.

Chart 3 – Third Level Evidence of Citizenship
Third Level Documents	Explanations and Notes on Documentation
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 US place of birth	Do not accept a souvenir “birth certificate” issued by the hospital. Note: For children under 16 the document must have been created near the time of birth or 5 years before the date of application
Life or health or other insurance record showing a US place of birth and was created at least 5 years before the initial application date	Life or health insurance may show biographical information for the person including place of birth; the record can be used to establish US citizenship when it shows a US place of birth.

Fourth Level Documents to Establish US Citizenship (Chart 4)

Fourth level evidence of US citizenship is documentary evidence of the lowest reliability. Fourth level evidence should ONLY be used in the rarest of circumstances. This level of evidence is used ONLY when primary evidence is not available, both secondary and third level evidence do not exist or cannot be obtained within 45 days for AR/AX or 90 days for SR/QM, and the applicant or recipient alleges being born in the US In addition, a second document establishing identity MUST be presented as described in Chart 5, Evidence of Identity. Available evidence is evidence that can be obtained within 45 days.

Accept any of the documents listed in Chart 4 as fourth level evidence of US citizenship if the document meets the criteria listed under “Explanations and Notes”, the applicant alleges birth in the US, and there is nothing indicating the person is not a US citizen (e.g. lost US citizenship). In addition, a second document establishing identity must be presented.

Fourth level evidence, as described below, consists of documents established for a reason other than to establish US citizenship and showing a US place of birth. The place of birth on the document and the application must agree. The written affidavit described in this chart may be used only when the State is unable to secure evidence of citizenship listed in any other chart.

Chart 4 – Fourth Level Evidence of Citizenship
Fourth Level Documents	Explanations and Notes on Documentation
Federal or State census record showing US citizenship or a US 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 Age. Add in the remarks portion “ US citizenship data requested.” Also add that the purpose is for Medicaid eligibility. This form requires a fee.
Other documentation as listed in the explanation that was created at least 5 years before the application for Medicaid	This document must be one of the following and show a US place of birth: Seneca Indian tribal census record Bureau of Indian Affairs tribal census records of the Navaho Indians US State Vital Statistics official notification of birth registration An amended US public birth record that is amended 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.
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 US place of birth	Admission papers generally show biographical information for the person including place of birth; the record can be used to establish US citizenship when it shows a US place of birth.
Medical (clinic, doctor, or hospital) record and was created at least 5 years before the initial application date and indicates a US place of birth	Medical records generally show biographical information for the person including place of birth; the record can be used to establish US citizenship when it shows a US place of birth. Note: An immunization record is not considered a medical record for purposes of establishing US 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 Affidavits	Affidavits should ONLY be used in rare circumstances. If the documentation requirement needs to be met through affidavits, the following rules apply: o There must be at least two affidavits by two individuals who have personal knowledge of the event(s) establishing the applicant’s or recipient’s claim of citizenship (the two affidavits could be combined in a joint affidavit). o At least one of the individuals making the affidavit cannot be related to the applicant or recipient. Neither of the two individuals can be the applicant or recipient. o In order for the affidavit to be acceptable the persons making them must be able to provide proof of their own citizenship and identity. o If the individual making the affidavit has information which explains why documentary evidence establishing the applicant’s claim of citizenship does not exist or cannot be readily obtained, the affidavit should contain this information as well. o IMA must obtain a separate affidavit from the applicant/recipient or other knowledgeable individual (guardian or representative) explaining why the evidence does not exist or cannot be obtained. o The affidavits must be signed under penalty of perjury.

Evidence of Identity (Chart 5)

When primary evidence of citizenship described in Chart 1 is not available, a document from charts 2 through 4 may be presented when accompanied by an identity document from this chart.

Chart 5 – Evidence of Identity
Documents to Establish Identity	Explanations and Notes on Documentation
Certificate of Degree of Indian Blood, or other US American Indian/Alaska Native tribal document.	Acceptable if the document carries a photograph of the applicant or recipient, or has other personal identifying information relating to the individual.
Any identity document described in section 274A(b)(1)(D) of the Immigration and Nationality Act	Use 8 CFR 274a.2(b)(1)(v)(B)(1). 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 US 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 Native American Tribal document US Coast Guard Merchant Mariner card data matches with other federal or state agencies, if the agencies establish and certify true identity of individuals. Such agencies may include food stamps, child support, corrections, including juvenile detention, motor vehicle or child protective services. Children who are age 16 or younger and cannot provide one of the documents listed above, may present one of the following documents: School record that shows a date and place of birth and parent(s) name Clinic, doctor or hospital record showing date of birth Daycare or nursery school record showing date and place of birth, or If none of the documents listed previously are available, an affidavit may be used. An affidavit is only acceptable if it is signed under penalty of perjury by a parent or guardian stating the date and place of the birth of the child and cannot be used if an affidavit for citizenship was provided. Exception: Do not accept a voter’s registration card or Canadian driver’s license as listed in 8 CFR 274a.2(b)(1)(v)(B)(1).

COLLECTIVE NATURALIZATION

The following will establish US citizenship for collectively naturalized individuals:

Puerto Rico
- Evidence of birth in Puerto Rico on or after April 11, 1899 and the applicant’s statement that s/he was residing in the US, a US possession, or Puerto Rico on January 13, 1941; or
- Evidence that the applicant was a Puerto Rican citizen and the statement that s/he was residing in Puerto Rico on March 1, 1917 and that s/he did not take an oath of allegiance to Spain.
US Virgin Islands
- Evidence of birth in the US Virgin Islands and the applicant's statement of residence in the US, a US possession, or the US Virgin Islands on February 25, 1927 ;
- The applicant’s statement indicating residence in the US Virgin Islands as a Danish citizen on January 17, 1917; residence in the US, a US possession, or the US Virgin Islands on February 25, 1927; and that s/he did not make a declaration to maintain Danish citizenship; or
- Evidence of birth in the US Virgin Islands and the applicant's statement indicating residence in the US , a US possession or territory, or the Canal Zone on June 28, 1932.
Northern Mariana Island (NMI) was formerly part of the Trust Territory of the Pacific Islands (TTPI)
- Evidence of TTPI citizenship; residence in NMI, the US, or a US territory or possession on November 3, 1986 (NMI local time); and the applicant's statement that s/he did not owe allegiance to a foreign state on November 4, 1986 (NMI local time);
- Evidence of TTPI citizenship, continuous residence in the NMI since before November 3, 1981, voter registration prior to January 1, 1975, and the applicant's statement that s/he did not owe allegiance to a foreign state on November 4, 1986 ; or
- Evidence of continuous domicile in the NMI since before January 1, 1974 and the applicant's statement that s/he did not owe allegiance to a foreign state on November 4, 1986 . If a person entered the NMI as a nonimmigrant and lived in the NMI before January 1, 1974, this does not constitute continuous domicile and the individual is not a US citizen.

TANF

Although TANF applicants and recipients are not required to provide documentation of citizenship, any document that is acceptable verification of citizenship for MA, will verify citizenship for TANF also. In addition TANF applicants and recipients can show citizenship based on the parentage or marriage of a US citizen. The following will establish US citizenship that is derived from a parental or spousal relationship to a US citizen:

DERIVATIVE CITIZENSHIP

Applicant Born Abroad to Two US Citizen Parents
- Evidence of the US citizenship of the parents, the relationship of the applicant to the parents, and that at least one parent resided in the US or an outlying possession prior to the applicant's birth.
Applicant Born Abroad to a US Citizen Parent and a US Non-Citizen National Parent.
- Evidence that one parent is a US citizens and that the other is a US non-citizen national, evidence of the relationship of the applicant to the US citizen parent, and evidence that the US citizen parent resided in the US, a US possession, American Samoa, or Swain’s Island for a period of at least one year prior to the applicant’s birth.
Applicant Born Out-of-Wedlock Abroad to a US Citizen Mother
- Evidence of the US citizenship of the mother, evidence of the relationship to the applicant and, for births on or before December 24, 1952, evidence that the mother resided in the US prior to the applicant’s birth or, for births after December 24, 1952, evidence that the mother had resided, prior to the child’s birth, in the US or a US possession for a period of one year.
Applicant Born in the Canal Zone or the Republic of Panama
- A birth certificate showing birth in the Canal Zone on or after February 26, 1904 and before October 1, 1979 and evidence that one parent was a US citizen at the time of the applicant’s birth or one parent was a US citizen and employed by the US government or the Panama Railroad Company or its successor in title.

For all other situations where an applicant claims to have a US citizen parent and an alien parent, or claims to fall within one of the categories, refer him/her to the local INS office for determination of the US citizenship. If the applicant is outside the US , refer him/her to the State Department for a US citizenship determination.

Adoption of Foreign-Born Child by a US Citizen
- If the birth certificate shows a foreign place of birth and the applicant cannot be determined to be a naturalized citizen under any of the above criteria, obtain other evidence of US citizenship; or
- Since foreign-born adopted children do not automatically acquire US citizenship by virtue of adoption by US citizens, refer the applicant to the local INS office for a determination of US citizenship if the applicant provides no evidence of US citizenship.
US Citizenship by Marriage

A woman who acquired US citizenship through marriage to a US citizen before September 22, 1922 requires evidence of US citizenship of the husband and evidence showing the marriage occurred before September 22, 1922 .

If the husband was an alien at the time of the marriage and became naturalized before September 22, 1922 , the wife also acquired naturalized citizenship. If the marriage terminated, the wife maintained her US citizenship if she was residing in the US at the time and continued to reside in the United States .

See TANF

See TANF, except proof of US citizenship may be requested when questionable. An applicant/recipient’s inability to provide proof of citizenship for Medicaid does NOT mean his/her citizenship is automatically questionable.