Use the Contact Tab to enter or update household contact information.

Residence

• Street-Line 1:^*
• Street-Line 2:
• City:^*
• State:^*
• Zip Code:^*

Mailing Residence

If mailing residence is the same as residential, check box “Same as Residence”. If it is different, enter mailing address.

Contact Methods

• What is the primary language spoken in the household?^*
• Where possible, we will send written communication in:^*
• How do you wish to receive your notices?^*
• Day Time Phone:
• Okay to leave message? Yes / No
• Night Time Phone:
• Okay to leave message? Yes / No
• Email:

Authorized Representative

• If the member or applicant wants a person outside the household to act on his behalf regarding any benefits the family may be qualified for, check Yes to the question “Is there an authorized representative for this case?”*
• First Name*
• Middle Name
• Last Name*
• Suffix
• Designation Privilege* (Select “Sign the application” if the authorized representative is completing the application. If not, select other option)
• Designation Start Date*
• Designation End Date*
• Organization Helping* (Select Yes or No)
• Street or P.O. Box:*
• Street – Line 2:
• City*
• State*
• Zip Code*
• Authorized Rep Phone*
• Email
• Who is giving authorization for this person to represent the case members?* (Select One)

Required fields are marked with an asterisk(*).

If the question regarding an Organization Helping is checked ‘Yes’, another box will open to enter the information for the Authorized Representative.