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Ted Head of Household DATE OF BIRTH DATE OF BIRTH SOCIAL SECURITY NUMBER STREET ADDRESS Telephone Number ( CITY, STATE, ZIP CODE ) Child s Case ID Info MAILING ADDRESS IF DIFFERENT THAN ABOVE (ADDRESS, CITY, STATE, ZIP CODE) CWS Case Name (Last, First, M.I.) CWS CASE NUMBER OTHER ID NUMBER CERTIFICATION SECTION (Place an X in each applicable box.) Applicant 1. Does the emergency meet the definition of Emergency Assistance because a child is at risk of abuse, neglect, abando.

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