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Get MI DCH-0682 2016-2024

Gnature and sworn to before me this day of Signature 20 Printed Name Signature and sworn to before me this Commission expiration date day of Commission expiration date QUALIFIED WITNESS SECTION – Facility Use Only (if not notarized, complete as defined on reverse of form) Signature of Father’s Witness Printed Name of Witness Signature of Mother’s Witness Printed Name of Witness Witness Place of Employment Witness Place of Employment Witness Work Address (Street, City, State, .

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