This page collects additional information about the authorized representative, and displays if you selected the Change checkbox for your Authorized Representative on the Basic Information page.
Some items have an asterisk (*) next to them, indicating they are mandatory. You must fill in these items before you can continue to the next page.
If you do not wish to change an Authorized Representative, click the Previous button to return to the previous page and choose No Change next to your representative’s name.
Type the desired Authorized Representative’s first and last name in the text boxes. Be sure to use the full, legal name. Do not use nicknames on this Redetermination/Change Report/Simplified Report. The First Name text box allows a maximum of 12 characters, and the Last Name text box allows a maximum of 19 characters. If the name does not fit in the boxes, type as much of the name as you can.
If you do not know the contact information for the individual you wish to name as an Authorized Representative, you may click the Save & Exit button to exit the online Redetermination/Change Report/LaCAP Re-Enrollment and save your progress on your Redetermination/Change Report/LaCAP Re-Enrollment. The Redetermination/Change Report/LaCAP Re-Enrollment is saved as Incomplete.
If the relationship of the applicant to the Authorized Representative is not listed in the relationship drop-down menu, select Related in another way.
Click the Print button to print this page for your reference.
Click the Next button to save and continue with the online Redetermination/Change Report/LaCAP Re-Enrollment.