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Get CA Attestation of Non Incarceration Status

Correct Applicant’s Signature: _____________________________________ Today’s Date: ___ /___ /____ MM Send your form two ways: 1. Fax to: 888-329-3700 (888-FAX-3700) 2. Mail to: Covered California PO BOX 989725 West Sacramento, CA 95798-9725 Page 1 DD YYYY .

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