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Commonwealth of Virginia Department of Social Services

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DOCUMENT METHODS AND DATES OF VERIFICATION REQUIRED BY PROGRAM(S) BEING EVALUATED. 1. MEMBER INFORMATION

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NAME LAST FIRST MI SOCIAL SECURITY NUMBER (# or APP mm/dd/yy)

DATE OF BIRTH

CITIZENSHIP/ ALIEN STATUS

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INDICATE ANY CHANGES TO THE ABOVE INFORMATION AND DOCUMENT METHOD AND DATE OF VERIFICATION.

032-03-823A-05-eng (09/2024) PERMANENT VERIFICATION LOG