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Get Sc Ebt Recertification Form

To: Name of Provider: Mailing Address: Provider Social Security Number: Form W-9 completed? Yes (First time only) Payment information may be reported to the IRS. If reported, provider will receive Form 1099 for tax reporting purposes. Name of Foster Child: Foster Parent Requesting Respite OR Name of College Youth Attends: Date(s) of Respite/Overnight Visits: Provider Signature: Date: Caseworker Signature: Date: FOR DSS STATE OFFICE ONLY Amount Due: Foster Parent Requesting Respite: Pro.

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