SFN 446, "Request to Claim 'Good Cause" 510-05-100-50

(Revised 6/01 ML #2590)

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The form provides the caretaker with the opportunity to describe the circumstances which he/she believes will have a bearing on the claim.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms . (44 kb pdf)

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