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3840 INSTRUCTIONS AND ELIGIBILITY REQUIREMENTS Instructions Except for section G, you must complete sections A through I, and sign and date this form, as well as any additional pages you may need to submit with it to provide further requested information. Please PRINT except when a signature is requested. If a dependent child is disabled and you want to continue his or her coverage beyond the limiting age describe this in Other Change in Section A, and attach proof of disabilit.

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