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Stions to the left of the heavy black line. The parent/legal guardian completes the non-shaded sections of this form instead of the BCJA 2 or SAWS 2 at redetermination only; the placement worker/county welfare department is to complete the shaded portions. The placement worker/county welfare department may complete all sections of this form instead of the BCJA 2 or SAWS 2 at application and redetermination when the parent/legal guardian is: ELIGIBILITY WORKER ONLY DATE: APPLICATION RE.

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