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4Cs 131-A Stony Circle Suite 300 Santa Rosa CA 95401 STATEMENT OF PARENTAL INCAPACITY Phone 707-544-3077 Fax 544-2625 PART I To be completed by the authorized agency representative and the incapacitated parent. By signing this form and for the purpose of verifying my incapacity to care for the family s children as it relates to the family s eligibility for subsidized child care and development services I authorize and request the health professional named in Part II to release the...
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