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PLANNED PARENTHOOD OF INDIANA & KENTUCKY Please use BLUE or BLACK ink only. ID verified by staff Today's Date: / /20 Chart Number: Last Name: First Name: MI: Social Security Number: Birth Date: /
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For the marital status section, indicate whether you are single, married, separated, or divorced.
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If you are separated, specify the date of separation and any legal documentation supporting your separation status.
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Single, married, separated, and divorced are different marital statuses that individuals may fall under.
Individuals are required to report their marital status as single, married, separated, or divorced on certain legal documents and tax forms.
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The purpose of indicating your marital status as single, married, separated, or divorced is to provide relevant information for legal and financial purposes.
On the form, you must report whether you are single, married, separated, or divorced as of the date specified.
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