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Get Dma 5153 2011-2025

Y Department of Social Services I, __________________________________________________, declare that I cannot provide two North Carolina state residency verification documents. I hereby declare that the above information is true and accurate. I understand that this declaration form is used to help verify that I meet North Carolina state residency requirements for Medicaid eligibility. I understand that a false or misleading declaration by me may result in Medicaid payments for which I would not.

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