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Ividual 001 EFT STATUS: Prenote Requested ORG CLASS: ADDRESS ID: PLEASE READ THIS CAREFULLY The information provided on this form will remain confidential and be kept by the Department of the AuditorController on behalf of Los Angeles County. Failure to provide the requested information may affect the processing of this form and may delay or prevent the receipt of benefits through the Direct Deposit Program. Return this form with the computer screen printouts attached by your Eligibility Work.

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