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Get UT DLD6a 2015

Rgan, eye and tissue donation? Do you wish to contribute a $1.00 donation to the “Mobility Assistance Fund?” Do you claim to be disabled under the Americans with Disabilities Act? Do you claim to be indigent and are applying for an ID card for voting purposes? Full Legal Name:________________________________ DOB:____/____/____ Iss. Date:____/____/____ BC PP DHS #:_________ Iss. Agency:___________ Required Docs Scanned Date:_____________________ SSN, ADDRESS, SAVE SSN:____-____-____ Dat.

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