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Get VA UAI Part A 2000-2024

: Rent 1 House: Other 2 Apartment 3 Rented Room 4 Name of Provider (Place) Admission Date Provider Number (If Applicable) Adult Care Residence 50 Adult Foster 60 Nursing Facility 70 Mental Health/Retardation Facility 80 Other 90 Where you usually live are there any problems? No 0 Yes 1 (Check All Problems That Apply) Describe Problems: Barriers to Access Electric Hazards Fire Hazards/No Smoke Alarm Insufficient Heat/Air Conditioning Insufficient Hot Water/Water Lack of/Poor Toilet Facilit.

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