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Get WI DHS F-60287 2013-2024

On of the person to whom mail from DHS/DQA is to be addressed.) Name – Designated Mail Recipient Title E-mail Address City Mailing Address State Zip Code List the names of all persons, age 10 and older, who live in the facility and are not a resident. If more than four names, attach an additional sheet. Last Name, First Name, and MI Relationship to Licensee Birth Date II. RESIDENT INFORMATION Total Resident Capacity Female Male Both Check the box indicating the primary client gro.

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