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Get KS KSFHP Self-Declaration Form 2015-2024

Ts, etc.) are supported by this income. I certify that the information that I provided is correct and I authorize Kansas Statewide Farmworker Health Program to use it. I understand that this information will be used to determine my eligibility for a Sliding Scale Discount for health services. Applicant Signature:_________________________________ Date:_________________ Comments: KSFHP – Revised September 2015 .

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