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TOTAL YEARLY INCOME Add lines 1 and 2 Read carefully and sign below I certify that the information on this form is correct. I reside in New York State and am not currently receiving full Medicaid bene ts. I know that I am required to give proof of my age income residency Medicare status and enrolled in EPIC. Please print names Mail this completed form to EPIC Albany NY 12212-5018 or Fax 518 452-3576 The information on this application is kept str....

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