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Get Mi Dhhs Cwl-259 2016

SPECIAL EVALUATION RECORD Michigan Department of Health and Human Services Division of Child Welfare Licensing and Adult Licensing DIRECTIONS FOR COMPLETING FORM: Please read the reverse side before completing this form. Please type or print so that the information completed can be read. Mail completed form to your agency s Licensing Consultant DCWL/Complaint Unit. SECTION I: DEPARTMENT INFORMATION (To be completed by Licensing Worker) Worker Name, Department Name, Address and Pho.

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