Health Insurance for Children and Pregnant Women eApplication cover sheet

Submission Date:   Applicant Name:   Confirmation Number:     Family ID Number:

Sign this page and Mail or Fax to FAMIS along with your proof of income and any other documents requested below. We must receive these documents within 30 days after your application was submitted.

FAX: 1-888-221-9402 Page 1 of               OR Mail: FAMIS P.O. Box 1820 Richmond, VA 23218-1820

By signing below, I certify that I have read my Rights and Responsibilities and agree to all the conditions and terms. I also agree that all information I have given on the application submitted online through www.FAMIS.org is true and correct to the best of my knowledge and belief. I understand that the information provided on this application can be used to establish identity for children under age 16. I also understand that if I give false information, withhold information, or fail to report required changes promptly or on purpose, health insurance coverage may be denied or ended and I could be prosecuted for perjury, larceny and/or fraud.

Sign Here: X X Date Name (please print):

Please send a copy of the following documents: This page with your signature Proof of income (Call 1-866-87FAMIS if you have any questions about the required proof.) If you are applying for a child or pregnant woman who is not a U.S. Citizen, please send a copy of the front and back of the Resident Alien Card for the child or other legal documents showing the child's immigration status.

Remember, we cannot process your application without your signature and the documents requested on this page.

If you have any questions, please call FAMIS at 1-866-87FAMIS (1-866-873-2647). Representatives are available Monday through Friday 8:00 am - 7:00 pm and on Saturday 9:00 am - Noon. Please allow at least two business days before calling FAMIS to check on the status of your application.

Family Access to Medical Insurance Security Plan A program of the Commonwealth of Virginia