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Get CA MC 210 A 2007-2024

____________________________________ Case Number _________________________ SUPPLEMENT TO STATEMENT OF FACTS FOR RETROACTIVE COVERAGE/RESTORATION My present circumstances, as listed on the Statement of Facts which I signed on ______________________, are true and correct statements, (Date) to the best of my knowledge, for the month(s) of ____________________________________________________ except as specified below. (for restorations, this should be the month in which the request is made) Circ.

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