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DENIAL REASON CODE WITHDRAWAL

LDSS-2921 Statewide (Rev. 7/16) DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION PAGE 1 CENTER/ OFFICE APPLICATION DATE UNIT ID WORKER ID CASE TYPE SERV. IND CASE NUMBER REGISTRY NUMBER VERS DISTRICT SUFFIX SNAP SUFFIX CATEGORY LANG NUMBER REUSE INDICATOR CASE NAME EFFECTIVE DATE DISPOSITION SERVICES TRANSACTION TYPE NEW OPENING REOPEN RECERTIFICATION DENIAL REASON CODE WITHDRAWAL ELIGIBILITY DETERMINED BY (WORKER): DATE ELIGIBILITY APPROVED BY (SUPERVISOR): DATE SIGNATURE OF PERSON WHO OBTAINED ELIGIBILITY INFORMATION DATE FORM _____ 0F _____ x DATE RECEIVED BY AGENCY EMPLOYED BY.

their siblings, and all parents of those children who live together. If you do not check whether a listed person is a United States citizen, national of the U.S. or an non -citizen with a satisfactory immigration status, or provide an U.S. Citizenship and …

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