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Get NY DOH-5088 2014-2024

DOH-5088 12/14 Identity Verification Form 1. Applicant Name 2. Address 3. City 4. State 6. Date of Birth mm/dd/yyyy 7. Verifying Your Identity We can verify your identity by reviewing your documents NY State of Health needs to verify your identity to finish processing your application and to give you access to your online account. You need to complete the form below and submit copies of the necessary documents. Please do not send originals. Once we verify your identity we can finish processing your application and you can gain access to your online account. If you submit a copy of a document from List A it must have your photograph or a physical description of you including information such as your name age sex race height weight and eye color. If you do not have a document from List A you can send copies of two documents from List B. The information on both documents from List B must match. If you are 18 years old or younger and do not have one document from List A or two documents from List B then you may submit one copy of a document from List C. Once you have completely filled out the form and collected copies of the documents listed below you can Mail them to NY State of Health PO BOX 11727 Albany NY 12211 OR Fax them to NY State of Health at 1-855-900-5557. NEED HELP WITH THIS FORM Call us at 1-855-355-5777. TTY users should call 1-800-662-1220 or 1-877662-4886 for TTY in Spanish. Social Security Number 8. Telephone Number List A Submit a copy of 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 Native American Tribal Document U*S* Coast Guard Merchant Mariner card Certificate of Naturalization List B OR Birth certificate Employer Identification card High school diploma College diploma List C Marriage certificate Divorce decree 5. ZIP Code High school equivalency diploma Property deed or title Hospital or clinic record Doctor s record N-550 or N-570 N-560 or N-561 Office of Refugee Resettlement Verification of Release Form 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 mm/dd/yyyy 11. Name type or print legibly 12. Relationship to applicant. Verifying Your Identity We can verify your identity by reviewing your documents NY State of Health needs to verify your identity to finish processing your application and to give you access to your online account. You need to complete the form below and submit copies of the necessary documents. Please do not send originals. You need to complete the form below and submit copies of the necessary documents. Please do not send originals. Once we verify your identity we can finish processing your application and you can gain access to your online account. Once we verify your identity we can finish processing your application and you can gain access to your online account. If you submit a copy of a document from List A it must have your photograph or a physical description of you including information such as your name age sex race height weight and eye color. .

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