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Ss: SS# Number of Dependents Categories of Assistance: Full Names of Dependents: 2. I hereby authorize (name of person and/or agency) to have access to my record on my behalf until 3. / (date). I hereby certify that I am the client named above. Date 4. / (Client's Signature) I find that the information in item 1 and the signature in item 3 match the information and signature in the client record. Date Name of Dept. Employee (Print) Signatu.

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