Apply for mediCAL. What do I write on form?

I’m applying for medical for my daughter and I but I’m not sure what it is I’m supposed to write on “Declaration under penalty of perjury” form? It looks kind of like the picture below. It just says department of employment and human services and at the bottom it says “I declare under penalty of perjury that the foregoing statements are true and correct, and I am aware that if I present any material matter as true which I know is false, I may be subjected to penalties prescribed for perjury under the Penal Code of the State of California in accordance with Section 11054 of the Welfare and Institutions Code.

@Mrs. B there isn’t anything on the reverse! 😅