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ER NAME/NO. LCSA WORKER NAME/NO. TELEPHONE NUMBER TELEPHONE NUMBER ( ( ) ) SECTION 1 - COMPLETE THE FOLLOWING ABOUT YOURSELF NAME (FIRST, MIDDLE, LAST) SOCIAL SECURITY NUMBER (SSN) BIRTHDATE MAIDEN NAME BIRTH PLACE STATE ZIP RACE HOME ADDRESS (STREET NUMBER AND NAME, APARTMENT NUMBER, IF ANY) CITY TELEPHONE NUMBER YOUR RELATIONSHIP TO CHILDREN YOUR RELATIONSHIP TO NONCUSTODIAL PARENT/UNMARRIED FATHER IN THE HOME ( Spouse Ex-Spouse Friend Other SECTION.

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