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Erify the members of a household in Public Assistance cases. For your convenience, we are providing this form to help you meet this requirement. It should be completed and signed by a person who: does not reside in your home; and is not related to either you or anyone else who is living in your household; and is knowledgeable about your situation. Please bring this form with you to the interview for (re)determination of your eligibility. The Montgomery County Department of Job and.

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