If you need assistance completing this form, please ask for help at your local county Job and Family Services office. We will submit your form to the local Board of Elections. Please complete the Voter Registration Form and submit it with your application. Step 4Īlong with your application, you have an opportunity to register to vote or change your address. All notices and correspondence issued by Medicaid must be issued to both you and the authorized representative. You may also have an authorized representative apply/renew on your behalf.Īn authorized representative is an individual, age 18 or older, who stands in your place. You must provide a written statement naming the authorized representative and the duties the authorized representative may perform on your behalf. You may mail, fax or drop off the application. Sign and date the application and send the application and any additional materials to your local county Job and Family Services office. If you are applying because you are age 65 or older or disabled, you will need to provide proof of your age or disability. Attach copies of your proof of income, resources (such as cash, savings, checking, real property, stocks, bonds, etc.), proof of citizenship or alien status, pregnancy if applicable, and other insurance you may have.
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