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Get DHS-1182-A

List below all minor children in your home for whom you are legally responsible. (Required for requested reimbursement of day care expenses) Home Address (Street Number and Name, Rural Route, PO Box No.) Child s Name City State D.O.B. Verified X Zip Home Telephone Number Cell Phone Number ( ( ) ) Previous or Other Names Used: How many hours do you wish to work per month? Do you have a valid Michigan Driver s license? Yes Do you have use of a motor vehicle? (If required in.

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