PIN, Tax ID, Property Identification Number
Year for which you are applying for
If your disability percentage has changed, please submit a new awards letter.
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Enter the name and address of the facility.
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
I state that to the best of my knowledge, the information contained on this application is true, correct, and complete
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