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Get 2378vr 2015-2024

DPA 2378H R-1-03 For more information call 1-800-252-8635 for persons using TTY 1-800-447-6404. IL478-1685 Instructions 1 INSTRUCTIONS Read the application carefully and follow all instructions. Illinois Department of Human Services Mail-In Application for Medical Benefits Esta solicitud est disponible en espa ol. This application is available in Spanish. Assets and Income of Spouse - Provide proof of a spouse s assets and income if anyone applyi.

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