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Get MN DHS-5576-ENG 2015-2024

proofs right away. „„Sign and date the form before returning. „„Call your worker if you have questions. 1. Name and address FIRST NAME MI LAST NAME DATE OF BIRTH PHONE NUMBER STREET ADDRESS CITY STATE ZIP CODE COUNTY MAILING ADDRESS (if different) CITY STATE ZIP CODE COUNTY 2. Has anyone moved in or out of your home in the past six months? No Yes – fill in below PERSON 1 FIRST NAME MI MOVED IN OR OUT? Moved in DATE OF CHANGE Moved out PERSON 2 FIRST NAME MOVED I.

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