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Get MN DHS-2120-ENG 2010

Rm: 1. Your REPORT MONTH(S) is ______________________ 2. Fill out and return this form or your benefits may be late or stop. 3. Answer Yes or No to each question. 4. If there is not enough room on the form to answer a question, attach your own pages. 5. Sign and date the form on or after ____________________ 6. Return this form no later than _______________________ ADA5 (5-09) This information is available in alternative formats to individuals with disabilities by calling your county worker. T.

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