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Get and Sign Mid Cares 2012 Form
Yes ⃞ No
Zip Code
4. Sign and date the application, then return
the application along with your income
documentation to:
Date of Birth
Number of all persons living in your home on a fulltime basis (adults and children)
MID CARES
P.O. Box 4060
Modesto, CA 95352-4060
2. Household Income
Household income includes money from all household members (taxable
or non-taxable), including but not limited to:
Wages ……………………………………
Workers compensation ……
Interest income ….…………………
Social Security...
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