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OMB Approval No. 2900-0160 Estimated Burden Avg. 30 min. STATE HOME PROGRAM APPLICATION FOR VETERAN CARE MEDICAL CERTIFICATION PART I - ADMINISTRATIVE STATE HOME FACILITY DATE ADMITTED GENDER M F RESIDENT S NAME Last First Middle This is a mandatory field SOCIAL SECURITY NUMBER. Mandatory field RESIDENT S STREET ADDRESS AGE CITY STATE AND ZIP CODE ADVANCED MEDICAL DIRECTIVE DATE OF BIRTH mm/dd/yyyy NO YES PART II - HISTORY AND PHYSICAL Use separa.

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