myFLFamilies.com
APPOINTMENT OF A DESIGNATED
REPRESENTATIVE
Case Number Customer’s Name
Completed by Customer Medicaid ID
I would like for ____________________________________ to act on my behalf in determining
Name of Representative
my eligibility for public assistance from the Department of Children and Families.
Signature of Customer Date
Completed by Representative
I understand that by accepting this appointment, I am responsible to provide or assist in
providing information needed to establish this person’s eligibility for assistance. I
understand that I may be prosecuted for perjury and/or fraud if I withhold information or
intentionally provide false information.
Signature of Representative Date
Relationship to Customer Street Address
City State
Phone Number
Self-Appointment by Representative
I am acting for ____________________________________ in providing information to
establish eligibility for assistance because he/she is unable to act on his/her own behalf. I will
provide information to the best of my knowledge. I understand that if I withhold information or if I
intentionally provide false information, I may be prosecuted for perjury and/or fraud. I agree to
immediately report any change in their situation of which I become aware.
Signature of Representative Date
Relationship to Customer Street Address
City
Phone Number
State
CF-AA 2505, PDF 03/2008 CNC Rev.01/11/2017
v.8.1.2016
