Georgia DFCS Form 216, the Declaration of Citizenship/Immigration Status, is the sworn statement every applicant for SNAP, Medicaid, or TANF in Georgia must sign to confirm the citizenship or immigration status of each household member seeking benefits. You can download a blank copy from the DFCS policy system or pick one up at your county DFCS office. The person completing it signs under penalty of perjury.1Georgia Department of Human Services. Division of Family and Children Services Declaration of Citizenship/Immigration Status
What the Form Asks For
Form 216 is a single page with two tables: one for children seeking benefits, one for adults seeking benefits. Each row collects the same five items for one person:
- Full legal name.
- Place of birth — city, state, and country.
- Citizenship status — check either U.S. Citizen or Lawfully Admitted Immigrant.
- Date naturalized or admitted — only if the person is a lawfully admitted immigrant.
- Immigration Document ID number — again, only for lawfully admitted immigrants.
The instructions say to complete “ONE or BOTH” of the statements depending on who in your household is applying.1Georgia Department of Human Services. Division of Family and Children Services Declaration of Citizenship/Immigration Status If both children and adults are applying, fill in both tables. Household members who are not applying for themselves do not go on the form — for example, a non-citizen parent whose U.S.-born child is the only one applying for Medicaid.
The form does not collect Social Security Numbers. Those are gathered separately on the main benefits application through Georgia Gateway.
Identity Documents You Need to Include
The form is a sworn statement, but DFCS also needs proof. Georgia law requires every applicant for a public benefit to provide a secure and verifiable document confirming lawful presence.2Georgia General Assembly. Georgia Code 50-36-1 – Verification Requirements, Procedures, and Conditions
For U.S. citizens, acceptable proof includes an original or certified birth certificate bearing an official seal, a U.S. passport, a State Department certification of report of birth, or a consular report of birth abroad. For lawfully admitted immigrants, acceptable proof includes a Permanent Resident Card (Form I-551), an Arrival/Departure Record (Form I-94), or another federal document specifying lawful immigration status. A foreign passport by itself is not enough; it has to be paired with a valid I-94 or similar federal immigration document.
The Georgia Attorney General maintains the full official list on the Department of Law’s website.3Justia. Georgia Code 50-36-2 – Secure and Verifiable Identity Documents Consular identification cards and matricula consular cards are specifically excluded, regardless of the holder’s immigration status.
Documents must be unexpired. You can submit them up to nine months before your application date, so long as they remain valid through the period you are applying for benefits.2Georgia General Assembly. Georgia Code 50-36-1 – Verification Requirements, Procedures, and Conditions
If the Applicant Is Under 18
A parent or guardian fills out Form 216 on the child’s behalf. The child does not execute the affidavit independently until within 30 days of turning 18.2Georgia General Assembly. Georgia Code 50-36-1 – Verification Requirements, Procedures, and Conditions A child born in the United States is a citizen regardless of the parents’ immigration status, so a certified birth certificate from any U.S. state or territory works as proof.
Filling Out the Form Step by Step
Start with the children’s table if any children in your household are applying. Write each child’s full legal name exactly as it appears on the birth certificate or immigration document. Enter city, state, and country of birth. Check either U.S. Citizen or Lawfully Admitted Immigrant. If you checked the immigrant box, write the date the child was admitted to the U.S. and the ID number from their immigration document.
Do the same in the adults’ table for every adult applying. Names, dates, and document numbers should match the supporting paperwork exactly. Small discrepancies — a middle name on the birth certificate that isn’t on the form, a transposed digit in an immigration ID — can trigger a verification delay.
At the bottom of the form, print your name on the attestation line, then sign and date it. The attestation reads: “I certify under penalty of perjury, that the information written and checked above is true.”1Georgia Department of Human Services. Division of Family and Children Services Declaration of Citizenship/Immigration Status That language carries legal weight without a notary. You are swearing to accuracy under the same standard as a court oath.
Where to Submit Form 216
Two main options.
Georgia Gateway
Fastest is uploading a scanned copy or clear photo through the Georgia Gateway portal at gateway.ga.gov. Log in, go to the document upload section, and attach the form along with copies of your supporting identity documents. The whole page needs to be visible and all text legible; blurry or cut-off uploads can delay processing.
Your County DFCS Office
Every Georgia county has a DFCS office that takes documents in person. Addresses and walk-in hours are at dfcs.georgia.gov/locations.4Georgia Division of Family and Children Services. Find a Location Appointments are available any day of the week at all DFCS offices upon request. When you hand-deliver paperwork, ask the front desk for a date-stamped copy for your records. You can also mail the form to your county DFCS office, using the address on that county’s page.
There is no single statewide mailing address. Forms go to the county office handling your case.
After You Submit
Form 216 is one piece of the application. DFCS won’t decide eligibility until every required document is in. If you checked “Lawfully Admitted Immigrant,” a DFCS worker verifies status through SAVE, the Systematic Alien Verification for Entitlements program run by U.S. Citizenship and Immigration Services. SAVE checks the immigration document number against federal records and often returns a result within seconds.5U.S. Citizenship and Immigration Services. About SAVE If the automated check is inconclusive, DFCS may ask you for more documents.
Overall processing deadlines depend on the program. Non-expedited SNAP is 30 calendar days from your application date;6Policy and Manual Management System (PAMMS). 3105 Application Processing – SNAP expedited SNAP is 7 days for households with less than $150 in monthly gross income and under $100 in liquid resources, or where shelter and utility costs exceed income and resources.7Policy and Manual Management System (PAMMS). 3110 Expedited Application Processing – SNAP Aged or blind Medicaid is 45 days; disabled Medicaid, which needs a separate disability determination, is 90 days.8Policy and Manual Management System (PAMMS). 2060 ABD Medicaid Application Processing
You receive a Notice of Decision in the mail when DFCS finishes. Georgia Gateway often shows the status before the paper notice arrives.
If You’re Denied
A denial tied to citizenship or immigration status, or any other reason, comes with the right to a fair hearing. You have 30 days from the date you receive the denial notice to request one, and the denial letter itself explains how. The hearing is conducted by an Administrative Law Judge from the Office of State Administrative Hearings. You can represent yourself or bring anyone you choose — an attorney, a relative, or a friend. You have the right to review your case file and the documents DFCS plans to use before the hearing, and at the hearing you can present evidence, bring witnesses, and cross-examine the agency’s witnesses.9Policy and Manual Management System (PAMMS). 17.16 Fair Hearings If the judge rules against you, you have another 30 days to request reconsideration.
Penalty for a False Statement
Because Form 216 is signed under penalty of perjury, knowingly providing false information is a criminal offense. Under Georgia law, making a false statement in any matter within the jurisdiction of a state agency carries a fine of up to $1,000, imprisonment for one to five years, or both.10Justia. Georgia Code 16-10-20 – False Statements and Writings, Concealment of Facts, and Fraudulent Documents in Matters Within Jurisdiction of State or Political Subdivisions The one-to-five-year range makes it a felony under Georgia’s sentencing framework. A false declaration also results in denial of benefits and can disqualify you from future applications.