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Get CA DE 1850 2004-2024

THIS FORM) I, , authorize the Employment Development Department to disclose my personal information, which is contained on this form, to the care recipient, the care recipient s authorized representative, and the physician or practitioner certifying hereon to the care recipient s mental incompetence or physical incapacity. Signature of Claimant: I, Date signed: , residing at NAME OF REPRESENTATIVE STREET ADDRESS , declare that I am the CITY, STATE, ZIP CODE of RELATIONSHIP , hereina.

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