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Te Name Birthdate Social Security Number Current Mailing Address (Street No. and Name) City State Zip Code Current Phone Number Other Name(s) By Which Known (Maiden Name, Previous Married Name(s), Other First or Last Name(s) Used) If you are mailing this form to the DHS office, please attach copies of your Driver s License or State of Michigan ID and your Social Security card and mail to your local DHS office Mecosta and Osceola County residents, return form to: MECOSTA / OSCEOLA DEP.

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