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BCDJFS 233 revised 03-01- 1 0 Butler County Job and Family Services Designation of Authorized Representative Applicant First Name I Case Number I Applicant Last Name State and Zip Code City Street Address Social Security Number Date Sent 1 authorize the following person or company to act as my representative i Middle Initial First Name Title I I Company Mailing Address Hornelcell Phone Last Name Work Phone State Zip This authority lasts until My .

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