New York State Essential Plan Application Form (Additional Information)
Please fill in the form accurately and honestly. Any incongruencies may delay the application process or result in rejection. All information will remain strictly confidential. 

3. Do you need to resubmit your telephone number?
4. Do you need to submit an I-94 number?
5. Do you need to submit a New York State residential address?
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6. Do you need to submit a mailing address?
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