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APPENDIX C Designation of Authorized Representative

APPENDIX C Designation of Authorized Representative You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an Authorized Representative . If you ever need to change your Authorized Representative , contact the Marketplace or the Department of Social Services in the County where you live ( ). If you re a legally appointed Representative for someone on this application, submit proof with the application. 1. Name of Applicant/ beneficiary 2. Name of Authorized Representative 3. Address Apt/Suite # 4. City 5. State 6. Zip code 7.

act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an “authorized representative.” If you ever ... Name of Applicant/Beneficiary ...

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