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Get Ny Map-3107a (mlf) 2015

Half of (Name of Medicaid Recipient/Surplus Program Applicant) ________________________were provided to me by the above named recipient. (Case Number) My relationship to the Medicaid Recipient is ______________________________________________________________ In signing this attestation, I certify that the statements above are true, correct, and complete with the full understanding that failing to tell the truth could result in loss of benefits for the above Medicaid recipient. (Your Signature.

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