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D D Unsigned forms (Sections C and D) will be returned.

AHC0208W Rev. 2022-01 Current Year Only - Based on 2021 Taxation YearApplication for Alberta Blue Cross Non-GroupCoverage Premium Subsidy 2022-2023 Please read the eligibility and program information in the information brochure before completing this application is only required if you have Alberta Blue Cross Non-Group form can only be used for the period April 1, 2022 to March 31, 2023 and is based on 2021 tax forms (Sections C and D) will be you have a spouse or partner, they must complete and sign (Sections G and H) on last name is My first name is My middle name isMy current mailing address isCity/Town Province/Territory Country Postal codeSection A - Account Holder s Personal Information (Please print)My personal heal

Unsigned forms (Sections C and D) will be returned. If you have a spouse or partner, they must complete and sign (Sections G and H) on reverse. My last name is My first name is My middle name is My current mailing address is City/Town Province/Territory Country Postal code

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Transcription of D D Unsigned forms (Sections C and D) will be returned.

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