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Get BCAL-414 2007

Designee, or for HFA only, Authorized Representative: Date of Signature: BCAL-414 (9-07) Department of Human Services (DHS) will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area. .

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