State identity proofing request form - DHS: Fill out & sign online

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Click ‘Get Form’ to open the State Identity Proofing Request Form in the editor.
Begin by entering your ABE Username, First Name, Last Name, Date of Birth, Phone Number, and Email Address in the designated fields. Ensure all required fields marked with an asterisk (*) are completed.
Fill in your Mailing Address. If this address differs from what is on file with the State, indicate whether you want to update it by selecting 'Yes' or 'No'.
Provide either your Social Security Number or Case/Application Number as instructed. Remember that only one of these is necessary.
Answer the questions regarding Medicaid services and representation accurately. If applicable, ensure you attach a signed Approved Representative form.
Review your entries for accuracy and completeness before signing and dating the form at the bottom.
Once completed, download or print the form and return it to the Illinois Department of Human Services as specified.

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