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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES WELFARE-TO-WORK (WTW) 24-MONTH TIME CLOCK EXTENSION REQUEST FORM PLEASE PRINT
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Document Date: 2015-01-08 12:23:07


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City

ZIP CITY / /

IndustryTerm

supportive services / /

Organization

HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES WELFARE-TO-WORK / /

Position

DATE PLEASE CONTACT YOUR WORKER / ID NO. WORKER / /

ProvinceOrState

California / /

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