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Street Address if available Printed name of adult signing the form Apt City Signature of adult State Zip Daytime Phone and Email optional Today s date INSTRUCTIONS Sources of Income Sources of Child Income Example s - A child has a regular full or part-time job where they earn a salary or wages - Social Security - Disability Payments - Survivor s Bene ts - A child is blind or disabled and receives Social Security bene ts - A Parent is disabled retired or deceased and their child receives...
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