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Although the above information is not required, having your contact information will expedite the investigation if we should need additional information. Where you see an asterisk * below, that information is required.
Name of Person Receiving Assistance
What would you like to report? Please check all that apply.
1. Recipient or person in the household is working?
Name of person employed:
2. Recipient is not employed where reported.
3. There is an unreported person living in the home. Name of person(s)
4. The recipient's children are no longer in the home. When did he/she move?
1st Child
Where is the child currently living?
2nd Child
3rd Child
5. Recipient owns the following vehicle:
Bank Account:
6. The recipient is receiving child support from the absent parent.What is the absent parent's name?
How much is he/she receiving?
7. The recipient does not live where he/she says he/she is living.
When did they start living there?
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