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ID STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10175 (09/13) STATEMENT OF IDENTITY FOR PERSONS IN INSTITUTIONAL CARE FACILITIES This statement
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Start by carefully reading the instructions provided on the form. Understand the purpose and requirements of the statement of identity.
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Fill in your personal information accurately. This may include your full name, address, contact information, date of birth, and social security number.
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Provide any additional identifying information requested, such as your driver's license number or passport details.
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If the statement of identity form requires you to provide proof of identity, make sure to attach the necessary documents. This could include a photocopy of your ID, birth certificate, or other official identification documents.
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Sign and date the statement of identity form at the designated space. Failure to sign the form may render it invalid.

Who needs a statement of identity form:

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Individuals undergoing a legal name change procedure may need to fill out a statement of identity form to provide proof and verification of their identity.
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Applicants for certain government processes or programs, such as applying for a new social security card or obtaining a passport, may be required to submit a statement of identity form.
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In some cases, individuals involved in legal matters, such as court cases or estate planning, may need to fill out a statement of identity form to establish their identity and credibility.
It is important to note that the specific situations and requirements for using a statement of identity form may vary based on your jurisdiction and the purpose for which it is being requested. Always consult the instructions provided with the form or seek professional advice when in doubt.
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The statement of identity is used to verify the identity of an individual and confirm that they are who they claim to be.
Individuals who are required to verify their identity for legal or administrative purposes are required to file a statement of identity.
The statement of identity form can be filled out by providing personal information such as name, date of birth, social security number, and any other identifying information requested.
The purpose of the statement of identity is to prevent fraud and ensure that individuals are accurately identified for legal or administrative purposes.
Information such as name, date of birth, social security number, and any other identifying information requested must be reported on the statement of identity.
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