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Statement is grounds for denying my application or revoking my foster care license and/or denying my application or withdrawing my approval as a foster care, kinship, guardianship or adoptive home should such licensure or approval have been based on the statement I have made herein. I understand this information is confidential and to be used by the Department of Public Health and Human Services/Child and Family Services Division for the administration of the foster care, kinship, guardianship a.

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