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Get Affidavit For Dependent Parents

PLEASE PRINT Participant s Name: Participant s SSN# or UID#: (First, Middle, Last Name) (UID# can be found on your BCBS I.D. Card) Dependent s Name: Child s Date of Birth: (First, Middle, Last Name) 1. The Participant is the child s Natural Mother / / Month Day Year Natural Father 2. Does your child reside with you? Yes No If not, with whom doe.

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