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HEALTHCARE POLICY & BENEFIT SERVICES DIVISION 55 Elm Street, Hartford, CT 06106 8607023480CO1303 (Rev. 07/15)STATE COUNTY AFFIDAVIT, being duly sworn, hereby depose and say:1. I am employed as the
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55 Elm Street Hartford is the address of a location in Hartford, Connecticut.
The individuals or entities responsible for activities at that location may be required to file.
The form or paperwork for 55 Elm Street Hartford should be completed with the necessary information.
The purpose of 55 Elm Street Hartford is to identify and provide information about the location.
Information such as the name of the occupant, type of business, and contact details may need to be reported.
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