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Get HI DHS 1266 2003

M TO: DATE: RE: SSN: BD: To Whom It May Concern: Employment and payroll record information on the above-named individual is being requested. Your immediate attention to this matter is appreciated. Please respond by: Thank You. (Eligibility Worker) (Unit Address / Telephone Number) I, , hereby give my permission for the release of information to the Department of Human Services regarding my employment and earnings. (Applicant/Recipient’s Signature) (Date) 1. Starting and ending dates o.

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