Publications
Page 19 of 21
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Client Rights and Responsibilities - W-0016RR Rev 1-23 - English
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Client Rights and Responsibilities - W-0016RRS Rev 1-23 - Spanish
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W-0534FH Fair Hearing Notice - Rev. 05-23
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W-0534FHS - Audiencia Imparcial - Rev. 05-23
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Request for Replacement SNAP Benefits
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Request for Replacement SNAP Benefits - Spanish
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Proof of Food Loss Form
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Proof of Food Loss Form - Spanish
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W-300MED - For Medicaid for the Employed Disabled - Rev. 12-19
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W-300SA - Medical Report For SAGA Cash Benefits - Rev.12-19
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W-300T19 - Medical Report For Title XIX Disability Determination - Rev.12-19
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W-650 - Authorization for Reimbursement of Interim Assistance - Rev. 09/10
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W-650S - Autorización para Reembolso de Asistencia Interina - Rev. 09/10
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W-675 - Report Form For Protective Services For The Elderly - Rev. 06/23
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W-682 - DIRECT DEPOSIT AUTHORIZATION FORM - Rev. 1-23