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APPLICATION FOR ELIGIBILITY AS A DISABLED DEPENDENT CHILD 19 YEARS OF AGE OR OLDERSubmit Form to: Suffolk County Employee Benefits Unit P.O. Box 6100 Haulage, NY 11788BY COMPLETING THIS FORM THE ENROLLED

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Anyone who wants to apply for a particular service or program offered by the application needs to fill out the submit form. This includes individuals, organizations, or businesses who are seeking assistance, requesting information, or applying for specific benefits.

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