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Get SC WKR009 (TEFRA) 2009

Y: ________________________ • • • • • If you do not return this form, your TEFRA Medicaid will stop. If you do not return proof of your income and resources, we cannot continue your Medicaid. Please fill out EACH item on this form. If an item does not apply, write “does not apply.” If an answer to any question is none or 0, write “none”. If you need help filling out this form, call your worker listed above. Si necesita ayuda para llenar este formulario, puede llamar a su traba.

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