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Form LG02 Revised 8/22LOCAL GOVERNMENT HEALTH INSURANCE PROGRAM STATUS CHANGE NONPARTICIPANT INFORMATION (Please print or type.) Name (First, Middle Initial, Last)Social Security Number Select the
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en-05-10012 is a form used to apply for a specific program or benefit. It is typically used to collect information from applicants.
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The purpose of en-05-10012 is to collect necessary information from applicants to determine their eligibility for a specific program or benefit.
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Applicants must report personal information, income details, and any other information relevant to the program or benefit being applied for.
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