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Get NY DOH-4220 2013

E: Child’s/adult’s name: No Yes Yes Student’s Name: How Often? (weekly, every two weeks, monthly) How Often? (weekly, every two weeks, monthly) How Often? (weekly, every two weeks, monthly) How Often? (weekly, monthly) No Yes Yes If yes, you must send a copy of the front and back of the insurance card with this application. SEND PROOF No NYS DOH SEND PROOF Yes Yes How often do you pay? 2 times a year ☐ Written statement from day care center or other child/adu.

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