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Your bene ts may be late or stop. 3. Answer Yes or No to each question. 4. If there is not enough room on the form to answer a question, attach your own pages. 5. Sign and date the form on or after ADA5 (12-12) This information is available in accessible formats for individuals with disabilities by contacting your county worker. For other information on disability rights and protections to access human services programs, contact the agency s ADA coordinator. 6. Retur.

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