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Rleaf. If a doctor, a registered nurse or Christian Science practitioner : the applicant is receiving treatment or care from me for the incapacity stated. Signed Name Address Date *Qualification/*Position *If the applicant does not live in a residential care home or sheltered accommodation, the declaration must be made by a doctor, a registered nurse or Christian Science practitioner. If the applicant lives in a residential care home or sheltered accommodation, the declaration can be signed.

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