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Welfare Fraud TipLine

 1-800-932-0582

Estate Recovery Statement of Claim Request

STATEMENT OF CLAIM REQUEST FORM

(PRIOR TO ENTERING NURSING HOME)
-
(###-##-####)
(MM/DD/YYYY)
(MM/DD/YYYY)
$ (up to $1,000,000)
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((###) ###-####)
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((###) ###-####)