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K or blue ink only. SECTION 1 1 2 5 LAST NAME Tell us about the person who wants Medi-Cal for themselves, their family or children in their care. FIRST NAME HOME ADDRESS (NUMBER AND STREET). DO NOT LIST A P BOX UNLESS HOMELESS .O. 6 COUNTY CITY/STATE 3 APARTMENT NUMBER 4 HOME PHONE # ( 12 CITY 14A WHAT LANGUAGE/DIALECT DO YOU SPEAK BEST? ) ( ) ( ) 8 WORK PHONE # 7 ZIP CODE 10 APARTMENT NUMBER 9 MAILING ADDRESS (IF DIFFERENT FROM ABOVE) OR P.O. BOX SECTION 2 MIDDLE INITIAL 1.

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