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Es www.mass.gov/masshealth Financial Information Request Name: Social security number: Address: City/Town/Zip: Name of financial institution: Address: City/Town/Zip: You or your spouse have applied for MassHealth. You must get a copy of your bank accounts to us so we can complete the application process. If you do not have your account records, you can get them from your bank. Sometimes banks charge a fee to get these records. You can get them at no cost with this form. You.

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