Declaration of Citizen/Noncitizen Status

IRCA Section 121 requires, as a condition of eligibility, that each person applying for public benefits (other than restricted Medi-Cal) must declare in writing under penalty of perjury whether the individual is a citizen or a national of the U.S., or what their noncitizen status is, to determine whether the individual is in SIS. A declaration of citizen/noncitizen status is required for each case regardless of citizen/noncitizen status.

The declaration of citizen/noncitizen status is required as follows:

At time of application.
At re-application and restoration when there is a break in aid:
- Of more than 30 days for CalWORKs and Medi-Cal.
- Of any duration for CalFresh.
Any time a noncitizen status change is reported.

IRCA Form Requirements

Statement of Facts - SAWS 2 Plus

For CalWORKs and CE CalFresh Households, the “Application for CalFresh, Cash Aid, and/or Medi-Cal/Health Care Programs” (SAWS 2 Plus) meets the IRCA requirements for a declaration of citizen/noncitizen status, when:

Each adult applicant/recipient signs under penalty of perjury that the individual is a U.S. citizen/national or noncitizen, and
The SAWS 2 Plus is documented for each individual, by initiating SAVE and checking the SAVE box, and
The EW verbally informs the noncitizen applicant/recipient of the requirements under IRCA.

CW 8 and CW 8A

The “Statement of Facts for an Additional Person” (CW 8) and the “Statement of Facts to Add a Child under Age 16" (CW 8A) meet the IRCA requirement for a declaration of citizen/noncitizen status when adding a person to an active CalWORKs/CalFresh case.

CFA 285

For CalFresh only households, the “Application for CalFresh Benefits” (CFA 285) meets the IRCA requirements for a declaration of citizen/noncitizen status.

SOC 814

The “Statement of Facts Cash Assistance Program for Immigrants (CAPI)”

(SOC 814) meets the IRCA requirements for a declaration of citizen/noncitizen status for CAPI applicants.

MC 13

A “Statement of Citizenship, Alienage, and Immigration Status” (MC 13) is required for each noncitizen Medi-Cal applicant/recipient, any adult citizen who did not sign a Statement of Facts, and an adult or child added to an existing Medi-Cal case. Refer to Medi-Cal Handbook, “Citizenship/Immigration Status,” page 6-1.

An MC 13 is NOT required to be completed for:

U.S. citizens, unless the adult citizen did not sign the Statement of Facts or the individual who is being added is not listed on the last Statement of Facts
Naturalized U.S. citizens. Refer to Medi-Cal Handbook, Section 6.4.4.
U.S. Nationals. Refer to Medi-Cal Handbook, Section 6.5.2.
Persons with Acquired or Derivative U.S. citizenship. Refer to Medi-Cal Handbook, Section 6.4.5.

An MC 13 must be completed for each individual who is a noncitizen, an adult citizen who did not sign the Statement of Facts and any individual being added to an existing Medi-Cal case who is not listed on the last Statement of Facts.

MC 13 must be completed at the following times:

Initial application
Reapplication
Restoration, or whenever there is break in aid of 30 days or more
Adding a person/program
Upgrading benefit level (e.g., from restricted to full-scope)
Change in noncitizen status of an aided person
When not previously completed.

Exception: If the applicant or recipient completes a SAWS 2 Plus and CalWORKs is denied but the family wants Medi-Cal, the SAWS 2 Plus can be used in lieu of the MC 13. The “Important Information for Persons Requesting Medi-Cal” (MC 219), must be given to the client, unless the SAWS 2 Plus was signed at application. The client’s signature is not required on the MC 219, however it must be documented that it was provided. Other Medi-Cal forms may be needed.

Medi-Cal/CalFresh Cases

For cases that receive Medi-Cal and CalFresh, an MC 13 is required for each noncitizen and adult citizen in the Medi-Cal MFBU who did not sign the Statement of Facts.

Completion of the MC 13

The applicant/recipient must follow these steps to complete the MC 13:

Enter name of applicant/recipient (first, middle, last) and date.
Enter name of person acting for applicant and relationship (e.g., parent for a child).
In Section B:
1. Check the appropriate box for Citizenship/Immigration Status.
2. Indicate specific Permanently Residing Under Color of Law (PRUCOL) status, if applicable, under question #5.
3. For the PRUCOL status (16th) that states, “An alien, not in one of the above categories, who can show that: (1) INS knows he/she is in the United States; and (2) INS does not intend to deport him/her, either because of the person’s status category or individual circumstances” the EW is NOT required to verify PRUCOL with SAVE.

Reminder: Nationals of the U.S. owe allegiance to the U.S. but are not citizens. Permanent residents of American Samoa are nationals of the U.S. and are eligible for benefits.

Verification: For CalWORKs, CalFresh, and Medi-Cal, Nationals must provide adequate verification to prove they are a national of the U.S.

In Section C:
1. Enter the Alien Registration Number. This is known as the “A” number. The “A” is followed by a seven, eight, or nine digit number.
2. Enter the date the applicant first entered the U.S.
3. Enter the applicant’s name when they first entered the U.S.
4. Enter the applicant’s country of citizenship.
5. Enter the place of birth (country where born).
6. Enter the Social Security number of each applicant/recipient.
In Section E:
1. Applicant’s Signature and Date
2. Signature of person acting for applicant and Date, if applicable.

Once the MC 13 is on file for current status, another form is not required at RRR unless the noncitizen status changes.

Reminder: EWs must complete the County Use Section of the MC 13.

Who Is Required to Sign

For Medi-Cal, the “Statement of Citizenship/Alien Status” (MC 13) must be signed and dated by:

Each noncitizen adult.
The parent or caretaker on behalf of his/her children under age 21.
The applicant for non-adults if there are no adults in the household.

Witness to Signature

The signatures do not have to be witnessed. If the noncitizen signs with an “X”, the signature must then be witnessed, but not necessarily by the EW.