Identity Verification Form

1. Applicant Name

2. Address

3. City

4. State

5. ZIP Code

6. Date of Birth

7. Social Security Number

8. Telephone Number

List A Submit One	OR	List B Submit Two	OR	List C Submit One
U.S. Passport book or card Foreign Passport book or card Driver’s license Official Government Identification card School Identification card U.S. military card or draft record Military dependent’s Identification card Native American Tribal Document U.S. Coast Guard Merchant Mariner card Certificate of Naturalization (N-550 or N-570) Certificate of U.S. Citizenship (N-560 or N-561) Office of Refugee Resettlement Verification of Release Form		Birth certificate Social Security card Marriage certificate Divorce decree Employer Identification card High school diploma College diploma High school equivalency diploma Property deed or title		Hospital or clinic record* Doctor’s record* *Applies to applicants 18 and younger only

Attestation: I attest, under penalty of perjury, that to the best of my knowledge, the information in and submitted with this form is true and correct.

9. Your Signature

10. Date

11. Name (type or print legibly)

12. Relationship to applicant

NEED HELP WITH THIS FORM? Call 1-855-355-5777. TTY users: 1-800-662-1220 or 1-877-662-4886 (Spanish).

NY State of Health

New York State Department of Health
Corning Tower, Room 2580
Albany, NY 12237

Effective today, __________________________ hereby designates Flatbush Insurance Brokerage, Clark Guo & Associates located at 871 Flatbush, Brooklyn, NY 11226 as my Broker of Record for health and dental plans offered in the NY State of Health Individual Marketplace.

This designation remains in effect until I notify the Marketplace in writing to the contrary.

Signature