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R AND WORKFORCE DEVELOPMENT DIVISION OF TEMPORARY DISABILITY INSURANCE INFORMATION TO BE COMPLETED BY THE CLAIMANT Print or Type WDS-1(R-2-08) Policy # 1. Name: Last First Middle 2. Birth Date 4. Home Address required (Street, Apt #, City, State, Zip Code) 6. Mailing Address if different (Street, Apt #, City State, Zip Code) 7. Male Female 3.Social Security Number 5. County 8. Occupation 9. Are you a citizen of the United States? Yes No 10. Alien Reg. No. 11. Work Aut.

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