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Get Form Adsa 1a - Cdss - State Of California - Cdss Ca

Es ADSA Program 744 P St., M.S. 6-94 Sacramento, CA 95814 Phone (916) 657-2628 / TTY (916) 651-6248 Please use the reverse side to show a change of name or address, or if your check is to be sent to a different address than the one shown here. Please complete, sign and return this form to the above address by . If you do not, you will be terminated from the Assistance Dog Special Allowance program. SSN: Date: 1. Are you receiving: SSI/SSP IHSS CAP.

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