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Get State Of California - Health And Human Services Agency California Department Of Social Services

Ited liability companies only. See reverse for public agencies, partnerships, and other associations.) INSTRUCTIONS: This form must be updated and submitted to the Licensing Agency each time there is a change in partners, officers or changes in the corporation or limited liability company as provided in the Callifornia Code of Regulations Title 22, Section 80034(a)(2), or 87235(a)(5), or 101185(a)(2). DATE FACILITY NAME FACILITY ADDRESS FACILITY NUMBER I. CORPORATION/LIMITED LIABILITY COMPANY.

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