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Get IN State Form 52690 2013-2023

Local DCS office Date (month, day, year) Name of requesting agency Address of agency (number and street, city, state, and ZIP code) Name of contact person Telephone number of contact person Fax number of contact person ( ( ) E-mail address ) There is a limit of $1,000 that may be expended for a youth throughout the provision of services to age twenty-one (21). Request #1 Total approved Request #2 Total approved Request #3 Total approved Request #4 Total approved INSTRUCTIONS: .

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