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Id Staff Use Only: District: ICLS CNTY BS C&A Fee waiver and application Match-Signed: HAVE YOU BEEN A CLIENT IN THIS OFFICE BEFORE? Language: Prob. Cod: Yes No If yes, when? What were you previously here for? Who referred you to us? Has CPS ever been involved with this case? Interpreter: CSR Report: Yes No Citizenship? Yes No DO YOU HAVE AN ATTORNEY Yes No Apt: Zip: Mailing address (if different than physi.

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