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FISHER Administrator BRIAN SANDOVAL Governor STATEMENT OF APPLICANT/RECIPIENT OR OTHER PERSON Case Name Case No Name of Person Making Statement Relationship to Applicant/Recipient Telephone Number Address Street City State Zip Subject Line Please write legibly Comments I know I must give complete and accurate information I understand that if I do not my benefits may be terminated or I may be fined and/or criminally prosecuted. I SWEAR MY STATEMENTS ARE TRUE. Signature Print Name...

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