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Get NY LDSS-4411 1999-2022

An, such as Plans provided by Employer, Unions, Retirement System; Coverage under Support Order, Private Insurance Plans or VA (Aid and Attendance)? Yes No Name of Covered Person(s) Who Pays the Premium Name of Insurance Company Policy Number Who Does the Policy Cover? Effective Date of Policy Amount of Premium and how often paid? HOUSING EXPENSES Does Your Spouse have a Housing Expense? If MONTHLY RENT AMOUNT Yes, Fill in the Requested Information. Yes No MONTHLY MORTGAGE AMOUNT $ $ MO.

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