Identity Information / State of Minnesota

* Indicates required information.

I want to complete an application for health care coverage. (You must complete the identify verification process.)

I want to appeal an action taken by an agency.

FIRST NAME *

MIDDLE NAME

LAST NAME *

NAME SUFFIX

STREET ADDRESS *

STREET ADDRESS LINE 2

CITY *

STATE *

ZIP *

ZIP+4

EMAIL ADDRESS

RE-ENTER EMAIL ADDRESS

PHONE NUMBER (###)###-####

SOCIAL SECURITY NUMBER - -

I do not wish to provide my Social Security Number *

DATE OF BIRTH (MM/DD/YYYY) *