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Eceived: Final Status/Date: Status/Date: Completed By: Purpose: This form is to recertify for the Insurance Assistance Program (IAP). I. ENROLLEE INFORMATION DAP ID: Last Name: First Name: Month/Year of Birth: Street Address 1: City: Mailing Address: Home Phone ( ) /XX/ Full Middle Name: Last 4 of SSN: XXX-XXStreet Address 2: State: Zip code: City: Other Phone ( Ethnicity (check one): o Hispanic/Latino (a): o Mexican o Non-Hispanic/Latino (a) Race (check all that apply): o American I.
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