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Clear FormDEPARTMENT OF RETIREMENT/LEAVE/UNEMPLOYMENT COMPENSATION Phone: 3059957090 Fax: 3055230495LETTER OF INTENTION OFFICE USE ONLY Approved TO: Not ApprovedSignatureDateOur records indicate that
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Fill in your personal information such as name, address, phone number, and email.
02
Provide details about the incident or situation for which you are making a claim.
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Any individual who is seeking to make a claim for an incident or situation they were involved in.
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1 form claimant took is the form submitted by individuals who are making a claim for a specific benefit or entitlement.
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1 form claimant took can be filled out by providing accurate and detailed information requested on the form.
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