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RE AND/OR CHILD CARE SIX-MONTH REPORT TO AVOID A DELAY IN YOUR FOODSHARE AND/OR CHILD CARE BENEFITS, ANSWER ALL QUESTIONS, SIGN AND RETURN THIS FORM BY TO THE AGENCY LISTED BELOW. IF THIS FORM IS NOT COMPLETED AND RETURNED BY YOUR FOODSHARE AND/OR CHILD CARE BENEFITS WILL END. CERTIFYING AGENCY: Case Number: Case Name: Worker Information Name: ID: Phone: -------------- COMPLETE THIS FORM USING BLUE OR BLACK INK. PLEASE PRINT. ----------Please enclose all papers that provide proof of your answe.

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