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COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE PO BOX 2675 HARRISBURG, PENNSYLVANIA 17105-2675 ADULT RESIDENTIAL LICENSING PHONE: (717) 783-3670 FAX: (717) 783-5662 November 7, 2011, Dear
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This form gives authorization for a specific action or transaction.
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The individual or entity responsible for authorizing the action or transaction must file this form.
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The purpose of this form is to legally authorize a specific action or transaction.
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