Dc Residency Form PDF Details

Accessing healthcare services through the DC HealthCare Alliance requires proving residency within Washington, DC, an essential step for individuals seeking medical assistance under this program. The DC Residency Form serves as a primary tool for this purpose, designed exclusively for applicants who need to establish their living status in the district. It offers a variety of documents that can be used to prove residency, including but not limited to a valid DC driver’s license or ID card, leases, rental receipts, or mortgage statements, alongside more detailed documents such as utility bills or paystubs that demonstrate local taxes being withheld. Should these forms of proof be unavailable, the form allows for verification by another DC resident or a local non-profit social services provider, who can attest to the applicant’s residency. This two-pronged approach ensures flexibility, especially important for those without traditional forms of identification or proof of address. Furthermore, it details the penalties for false information, underscoring the seriousness of the application process, and outlines an expectation for cooperation with state officials in verifying the provided information. Last updated in 2009, the form reflects ongoing efforts to make healthcare accessible while ensuring that only eligible DC residents benefit from the DC HealthCare Alliance.

QuestionAnswer
Form NameDc Residency Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdc proof of form, dc proof of residency form, dc residency form, proof of dc residency form

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DC HEALTHCARE ALLIANCE

PROOF OF DC RESIDENCY FORM

DC HealthCare Alliance (Alliance) is ONLY for people who live in Washington, DC If you are applying for medical assistance through the DC HealthCare Alliance, you must show that you are a DC resident.

You can show that you live in DC with a valid DC driver’s license or ID card, a lease, rental receipt, deed, settlement papers, or mortgage statement for a DC residence, home owner’s or renter’s insurance policy, a property tax bill, a utility bill, a paystub showing address and DC taxes withheld, or a voter registration card showing your name and DC address. If you do not have any of those documents, you can also prove that you live in DC using this form. Another DC resident who knows where you live can verify your residency by filling out Section B, or a local non-profit social services provider can verify your residency in Section C.

Section A: Your Information (Required)

Last Name: __________________________________ MI: _____ First Name:

Home Address:

City, State, Zip:

Are you homeless?

YES

NO

Section B: Individual Verifier’s Information This section must be filled out by a DC resident who knows where you (the applicant) live—someone you live with is best. If you do not know anyone who is willing or able to verify where you live, a local non-profit organization that provides you with services may complete Section C for you. (You do not need to fill in Section C if this section is completed.)

Last Name: _________________________________ MI: ____ First Name:

Home Address:

E-mail: ________________________________ Telephone Number:

How do you know the applicant?

The verifier must sign this form and provide a copy of at least one (1) of the following documents showing the verifier’s name and DC address:

-Valid DC driver’s license or non-driver’s ID

-DC voter registration card

-Valid lease, rental agreement, rent receipt, deed, settlement papers, or mortgage statement for a residence in the District

-Valid homeowner’s or renter’s insurance policy for a residence in the District

-DC Property tax bill issued within the last sixty (60) days

-Utility bill (water, gas, electric, oil, cable, or landline telephone) issued within the last sixty (60) days

-Paystub received within the past thirty (30) days showing DC address and DC withholding taxes

I understand that the DC HealthCare Alliance is ONLY available to people who live in the District.

By signing below, I verify that, to the best of my knowledge, the applicant listed above lives in the District of Columbia.

I know that if I give any false information, I may be breaking the law and may have to pay a fine of up to $500, or go to prison for up to a year, or both (D.C. Code § 4-218.01). I know that state officials will check this information and I agree to cooperate with their information requests.

Verifier’s Signature: _____________________________________________ Date: ______________________

Last revised: September 3, 2009

Section C: Organizational Verifier’s Information This section must be completed by a DC non-profit social services provider, such as a homeless shelter, community health center, immigrant services provider, legal clinic, or religious organization that serves you (the applicant). (You do not need to fill in Section B if this section is completed.)

Organization Name:

Organization DC Tax-Exempt ID:

Verifier’s Name:

Verifier’s Title:

Telephone Number:

 

E-mail:

Organization Address:

City, State, Zip:

I understand that the DC HealthCare Alliance is ONLY available to people who live in the District.

By signing below, I verify that, to the best of my knowledge, the applicant listed above lives in the District of Columbia.

I know that if I give any false information, I may be breaking the law and may have to pay a fine of up to $500, or go to prison for up to a year, or both (D.C. Code § 4-218.01). I know that state officials will check this information and I agree to cooperate with their information requests.

Verifier’s Signature: _____________________________________________ Date: ______________________

Remember: Before you turn in this form, make sure it is complete.

You must have:

-Section A filled out AND

-Section B OR Section C completed AND

-If you use Section B, you must have a copy of the individual verifier’s proof of residency.

To report waste, fraud and abuse by any DC Government agency or official, call the D.C. Inspector General at 1 (800) 521-1639.

Last revised: September 3, 2009

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proof of dc residency form completion process outlined (stage 1)

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Step # 2 for completing proof of dc residency form

3. In this step, look at Section C Organizational Verifiers, Organization DC TaxExempt ID, Verifiers Name, Verifiers Title, Telephone Number Email, Organization Address, City State Zip, I understand that the DC, By signing below I verify that to, and I know that if I give any false. Each one of these need to be filled in with utmost precision.

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