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Fillable Online DESIGNEE DECLARATION Saha Org Fax 2019-2023
That the statements therein are true and correct. DESIGNEE DECLARATION Please note that the below designee will only be approved by SAHA if they are either a granted Power of Attorney b approved as a Reasonable Accommodation by SAHA for a person with disabilities or c authorized as a caseworker from a SAHA partner agency. APPLICANT/PARTICIPANT INFORMATION Name Last 4 SSN Home Phone Cell Phone Work Phone Email Address Current Address City State Zip Code DESIGNEE INFORMATION I authorize to...
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