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Indiana Health Coverage Programs E V O C A T I O NO FA U T H O R I Z A T I ON Section A: Statement of Revocation
I revoke my previous authorization, or part of my previous authorization, for the Indiana
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Start by reading the instructions carefully to understand what information is required in Section A.
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Section A statement is a declaration of assets, liabilities, incomes, and expenditures.
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Assets, liabilities, incomes, and expenditures must be reported.
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