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PROTESTAPPEAL of a REDETERMINATION STATUS Michigan 2020-2023
INFORMATION
Name and Address
If business, enter DBA, Trade or Assumed Name
Telephone Number
Extension
Fax Number
FEIN Number
UIA Account Number
*
E-mail Address
PART 2: REPRESENTATIVE INFORMATION AND AUTHORIZATION DATES
Your authorized representative may be an organization, firm, or individual. If your representative is not an individual, designate a contact person.
Please ensure that you submit a separate form for each representative.
Representative Name and Address
Contact...
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