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Get MI DHS-4574 2013

Edition obsolete. FOR OFFICE USE ONLY ASSETS DECLARATION PATIENT AND SPOUSE Grantee Name Michigan Department of Human Services (Skip if no spouse) Grantee Client ID Case Number County District Section Unit Specialist PLEASE PRINT Patient’s Name (First, Middle, Last) Phone No. of Nursing Home Address of Nursing Home (Number, Street, Rural Route) Spouse’s Name (First, Middle, Last) Spouse’s Phone No. Spouse’s Address (Number, Street, Rural Route) City State Zip Code C.

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