Free affidavit of identity 43Free affidavit of identity 43
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Iowa Department of Human Services
Kim Reynolds

Adam Gregg
Lt. Governor

Jerry R. Foxhoven


Re: Identity of
Please get the attached Affidavit of Identity completed for the person named above. It
must be completed by someone (other than the person named above) who knows the
identity of the person named above.
Please return this form by ___________________. If you need more time to return the
form, please call me before the due date and let me know. If you do not return the form
or ask for more time by the due date, Medicaid/hawk-i or family planning benefits for
this person may be canceled or denied. If you have any questions, please call me at
the number listed below.
Thank you.

Income Maintenance Worker

470-4386 (Rev. 6/18) W4386A

Original: Family

Copy 1: Control

Worker No.
State ID
Case No.
Iowa Department of Human Services

Affidavit of Identity
1. Information about the person needing to verify identity
The person’s ful