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Get SC WKR009 (TEFRA) 2016-2024

your TEFRA Medicaid Coverage You must return this form to us by: • • • • • If you do not return this form, your TEFRA Medicaid will stop. If you do not return proof of your child's income and resources, the TEFRA Medicaid will stop. 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 llen.

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