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Get WA DSHS 14-224 2010-2024

Nd Health Services is in the process of determining this client’s eligibility. Please provide the information requested below. PROPERTY OWNER OR AUTHORIZED MANAGER: Complete all sections below with only the information you know to be true. Write “unknown” to questions you can’t answer. (Do not leave any box blank.) FINANCIAL SERVICES SPECIALIST’S SIGNATURE A. Rental or leased unit and tenant information: 1. STREET ADDRESS APARTMENT (APT) NUMBER CITY STATE 5. NAMES OF ALL ADULTS .

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