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Get CA CW 60 2001

Re and Institutions Code Section 11286(a). COUNTY USE ONLY Enter name and address of institution WORKER NAME CASE NAME CASE NUMBER DATE I authorize you to release to ___________________________County information on the account(s) below and other information required for the purpose of determining my eligibility for public assistance. I understand I have the right to stop this authorization at any time, but that failure to cooperate may affect my eligibility. This authorization is valid for .

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