ࡱ>  @ G bjbj %'<1<1<18|"<PVht1L3b3b3b3=44\+50RMUMUMUMUMUMU$WR ZqUj8=4=4j8j8qUb3b3 V:::j8(b3b3R:j8R::J|!Lb3^ b$<18L%K?M\ V0PV7KZ8Z$!LZ/L[55h:U6T6[5[5[5qUqU":"JUVENILE GUARDIANSHIP CONSENT REQUEST FOR MCI WARDSState of MichiganDepartment of Human ServicesChild s Name (Last, First, Middle)Date of BirthSWSS Log Number FORMTEXT       FORMTEXT       FORMTEXT      DHS Local OfficeName of Recommended Juvenile Guardian(s): FORMTEXT       FORMTEXT       FORMCHECKBOX  Foster Parent FORMCHECKBOX  Relative FORMCHECKBOX  OtherInstructions: Complete either Section A or B, and all of Section C.A. FORMCHECKBOX EXPEDITED CONSENT REQUEST (All of the following must apply):Date placed in the home: FORMTEXT       FORMCHECKBOX The child has resided in the prospective guardian s home for a minimum of six consecutive months and all of his/her physical and emotional needs are being satisfactorily met. FORMCHECKBOX The home is a licensed foster home. FORMCHECKBOX Criminal record checks, including fingerprint based check for guardian, and CPS clearances for all adults in the home are current (see foster care policy) no arrests or convictions. FORMCHECKBOX The family has no previous complaints (licensing and/or CPS) involving the care of a child.B. FORMCHECKBOX REGULAR CONSENT REQUESTDate placed in the home: FORMTEXT       FORMCHECKBOX The child has resided in the prospective guardian s home for a minimum of six consecutive months and all of his/her physical and emotional needs are being satisfactorily met. FORMCHECKBOX The home is a licensed foster home. FORMCHECKBOX The family has previous licensing, protective services, or criminal complaints. FORMCHECKBOX There are other circumstances existing that require additional documentation.C.ALL OF THE FOLLOWING ARE REQUIRED FOR EACH CONSENT REQUEST: FORMCHECKBOX Foster care license number: FORMTEXT      Date of licensure: FORMTEXT       FORMCHECKBOX Copy of the current foster care licensing evaluation. FORMCHECKBOX Copy of the child s birth certificate or other verification of birth. FORMCHECKBOX Copy of the childs USP that includes the required report elements for juvenile guardianship as defined under Case Plan Requirements. FORMCHECKBOX Legal documentation (A copy of at least 1 of the following legal forms is included):A copy of the Order Terminating Parental Rights, Commitment to DHS (JC63). The applicable legal documents committing a child to DHS following a voluntary release (PCA 305, 306, 312, 318, 322). Combination of a and b above. Order committing a child to MCI (following a disrupted adoption).Placement Agency and Address FORMTEXT      Signature of Foster Care CaseworkerDateTelephone Number FORMTEXT       FORMTEXT      FORMTEXT      Signature of Foster Care Supervisor Approving the GuardianshipDate FORMTEXT      Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.AUTHORITY: MCL 710.21 et. seq. and P.A. 280 OF 1939 RESPONSE: Required. PENALTY: Guardianship delay. DISTRIBUTION: Original Central Office; Copy Retain for your fileREQUIREMENTS TO REQUEST CONSENT FOR JUVENILE GUARDIANSHIP OF MCI WARDS LEGAL AUTHORITY The Superintendent of the Michigan Childrens Institute (MCI) represents the state as guardian of state wards beginning with the date of the childs commitment and continuing until the age of 19 (MCL 400.203). The MCI Superintendent is authorized to consent to adoption, juvenile guardianship, medical procedures, marriage, or emancipation according to the laws for adoption, juvenile guardianship, marriage or emancipation (MCL 400.209 and MCL 712A.19c). CONSENT TO JUVENILE GUARDIANSHIP The authority to grant consent to juvenile guardianship for state wards rests with the MCI Superintendent. State wards include children who have been committed to the state through involuntary termination of parental rights in the Family Division of a Circuit Court (PA 220 of 1935), or through release of parental rights by the legal parent(s) or private child placing agency to whom the child has been previously released (PA 296 of 1974). The MCI Superintendent must approve juvenile guardianship of any state ward. The request for consent from the placing agency is a recommendation that the family be granted consent by the MCI Superintendent. In requesting consent for the juvenile guardianship of a child, the Juvenile Guardianship Consent Request form must be completed and sent with required documentation to the MCI Superintendent, Adoption Services Division-Central Office. The Superintendent may request additional information or actions prior to issuing a decision regarding consent. Juvenile Guardianship Consent Packet Juvenile Guardianship Consent Request Form. *fhj2 P R T V j l n x z | ~  ( B F H \ ^ ` j l n p ټǮ٣Ǯ٘ǮًُـǮj\hwEUhJh+5OJQJjh+UjfhwEUjhUmHnHujhwEUjh+U h+CJh*.h+ho2h3ho2h35ho2h+5 h+5 h[50hjsj $Ifgdo2<kdX$$Ifl4,,4 lalf4 $Ifgdo2<kd$$Ifl4,,4 lalf4 $Ifgd3 B 2 R |<kd$$Ifl4,,4 lalf4 $Ifgd(,<kd$$Ifl4,,4 lalf4R T | 0bkdN$$Ifl4F^k#,^      4 lalf4 $Ifgdo2bkd`$$Ifl4F^k#,^      4 lalf4 D F n MD $IfgddOkdD$$Ifl40$ ,$ [#4 lalf4 $Ifgdo2Okd$$Ifl40$ ,$ [#4 lalf4 $Ifgd N    0 2 4 6 @ F Ǽ֞Ǽ֞Ǽm֞ea]Sjh0J#UhHhh MYh MY5*jhh5CJOJQJU*j4hh5CJOJQJU hI5h+hd5*jhh5CJOJQJUh+hd0J#CJjh+hd0J#CJUhdho2jhUmHnHujh+UjhwEU  B D F ZQ $Ifgd MYkd$$Ifl4ֈ$ V$',$ 2 ad4 lalf4 $Ifgdd t ~~ $Ifgd`$$If^a$gd MY $Ifgd$d8$If^a$gddLkd$$Ifl4,,  4 lalf4p  , . r t ǽ{pb^W^I^WD hH5hhH0J#5OJQJ ho2hHhHjhUmHnHuj hUhjhUhdhH5hdh5hhH0J#5@OJQJhh@CJaJhh@hh5@hh5>*@hdhH0J#jh0J#U&jhh5OJQJU h0J# cPPG7$$If^a$gd MY $Ifgd$d8$If^a$gddkd $$Ifl4ֈ3"+,{ 4 lalf4  ZM:$d$If^a$gdd $If^gdwEkd $$Ifl4pֈ3"+,{ 4 lalf4 $Ifgd`    @ X 12345CDEFijklm{|}~56789GHIJpqjWhUhHjhHU ho2hHhhIj/hUjhUj hUh<]jh<]U ho2h<]hJj hUhdjhdU ho2hd1 234Fjl\$$If^a$gd<]$d$If^a$gd<] $If^gd<]bkdU $$Ifl4F3,L)    4 lalf4$$If^a$gddjkl~6|l$$If^a$gdd$d$If^a$gdwE $If^gdwEbkdo $$Ifl4F3,L)    4 lalf4678J|l$$If^a$gdwE$d$If^a$gdwE $If^gdwEbkd$$Ifl4F3,L)    4 lalf4|llcl $IfgdH$$If^a$gdwE$d$If^a$gdwE $If^gdwEbkd$$Ifl4F3,L)    4 lalf4   "$@BDF     #),mxhJhN>*hJjhUjehUhjKhUhNjhNU ho2hNhdhH0J# ho2hHjhUmHnHujhUjhHUhHhdhH5 hH5>*/cZZZZZZ $Ifgdkd5$$Ifl4ֈ3"+,i2 4 lalf4 "FcVC3$$If^a$gdN$d$If^a$gdN $If^gdNkdG$$Ifl4pֈ3"+,i2 4 lalf4 |l$$If^a$gdN$d$If^a$gdN $If^gdNbkd$$Ifl4F3,L)    4 lalf4   ny$d$If^a$gdN$$If^a$gdNbkd$$Ifl4F3,L)    4 lalf4mnopq%&'(CDEOP  246JLNXZ^`bhjlʿַַֆ ho2hIDhZ5OJQJjhWUjhUmHnHujhWUhIDjhIDUjhUhZjhZU ho2hZ hN5jhUjhNUhN ho2hN0nopy$d$If^a$gdN$$If^a$gdNbkd$$Ifl4F3,L)    4 lalf4yi$$If^a$gdN$d$If^a$gdN$$If^a$gd&bkd $$Ifl4F3,L)    4 lalf4<Okdm$$Ifl40,*4 lalf4$$If^a$gd&bkd$$Ifl4F3,L)    4 lalf4(D4\^ $IfgdZ$$If]^a$gdZ$d$If^a$gd&^`bdfP@-@$d$If^a$gd&$$If^a$gd&kdu$$Ifl4֞3 +,e A  4 lalf4fhjy$d$If^a$gdW$$If^a$gdWbkd$$Ifl4pF3,L)    4 lalf4$&(*:Cz{|}RTVjθδΩΥΥΥδΟhjhU hNCJhj!hUhJjhUjhUhNjhNU ho2hNhID ho2hIDjhIDUjQhU7y$d$If^a$gdW$$If^a$gdWbkd$$Ifl4F3,L)    4 lalf4*y$d$If^a$gd&$$If^a$gd&bkdk$$Ifl4pF3,L)    4 lalf4y$d$If^a$gd&$$If^a$gd&bkd$$Ifl4F3,L)    4 lalf4{w$d$If^a$gdID$$If^a$gd&bkd+$$Ifl4pF3,L)    4 lalf4{|}~y$d$If^a$gd&$$If^a$gd&bkdE $$Ifl4 F3,L)    4 lalf4y$d$If^a$gdL$$If^a$gdLbkd $$Ifl4pF3,L)    4 lalf45rrrr$ & F VV$If^V`a$gdI $If^gdLbkd "$$Ifl4F3,L)    4 lalf4RT|i` $Ifgd<kd]#$$Ifl4,,4 lalf4 $IfgdLOkd"$$Ifl4 0*,*U)4 lalf4jlnxz  468>@BDXZ\fhjl "$&*+,uڶګڠڕچچ~hc hN5 hLhNho2hN5hN5CJOJQJj'hNUj&hNUj%hNUj/%hNUjhNU hNCJhNjhUmHnHujhUj#hU0|~jVMMM $IfgdLbkd$$$Ifl4Flf!,l     4 lalf4 $IfgdL<kd7$$$Ifl40,,4 lalf4jl C:: $IfgdLOkd'$$Ifl40f!,f! 4 lalf4 $IfgdLbkdm&$$Ifl4Flf!,l     4 lalf4 "$&+i]III &@d$If^gd#X $$Ifa$gd1<kdm($$Ifl4m,,4 lalf4 $IfgdLOkd'$$Ifl40f!,f! 4 lalf4+,rst_<kdU)$$Ifl4,,4 lalf4 +<$If^gdc Okd($$Ifl40l,l4 lalf4tu######}$ & F V@$Ifa$gdc $ & F$Ifa$gdc $$Ifa$gdc $$Ifa$gdc <kd)$$Ifl4*,,4 lalf4EM!!^"f""""######q &(*>@BLܽ൱jhYqUmHnHuj6+hYqUj]*hYqUhYqjhYqUhf hf 0JmHnHu h0Jjh0JUhh(VUhhJhNhc hN5 hJ57Copy of childs birth certificate. Order Terminating Parental Rights/Commitment to the Department of Human Services (JC 63). If the case was a voluntary release: Release of Child By Parent (PCA 305). Release of Child By Agency (PCA 306). Order Terminating Parental rights After Release or Consent (PCA 318). Order Committing to Department of Human Services. Copy of Foster Care Home Evaluation and foster home license number. Copy of Caseworkers Permanency Planning Checklist (DHS-2052). Copy of Caregivers Permanency Planning Checklist (DHS-2051). Copy of case plan/USP addressing the required elements: The steps the agency has taken to determine that it is not appropriate for the child to be adopted. The reasons for any separation of siblings during placement. The reasons why a permanent placement with guardian through a guardianship assistance arrangement is in the childs best interest. The ways in which the child meets the requirements for a guardianship assistance payment. The efforts the agency has made to discuss adoption by the childs relatives or foster parents as a more permanent alternative to legal guardianship and, in the case of a relative foster parent who has chosen not to pursue adoption, documentation of the reasons. The consent packet should be combined with the DHS-3310, Certification of Guardianship Assistance Eligibility and Request for Agreement and sent to: Michigan Department of Human Services Subsidy Office Suite 412 P.O. 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MYINFO.ini DB@tUserInfoPhone P!\ MYINFO.ini DB@tUserInfoYourExt P!& MYINFO.ini DB@tUserInfoFaxAC P!( MYINFO.ini DB@tUserInfoFax P!* MYINFO.ini DB@tUserInfoOffice P!^ MYINFO.ini DB@tUserInfoAddress P!` MYINFO.ini DB@tUserInfoCity P!b MYINFO.ini DB@tUserInfoState P!d MYINFO.ini DB@tUserInfoZip P!f MYINFO.ini DB@tUserInfoCO P!h MYINFO.ini DB@tUserInfoDI P!j MYINFO.ini DB@tUserInfoSEC P!l MYINFO.ini DB@tUserInfoUN P!n MYINFO.ini DB@tUserInfoWKR P!p MYINFO.ini DB@tUserInfo Boss Name P!@ MYINFO.ini DB@tUserInfo Boss Title P!B MYINFO.ini DB@tGet user info from INI fileUserInfoName MYINFO.ini D%X' UserInfoTitle MYINFO.ini D%X' UserInfoAreaCode MYINFO.ini D%X' "UserInfoPhone MYINFO.ini D%X' $UserInfoYourExt MYINFO.ini D%X' &UserInfoFaxAC MYINFO.ini D%X' (UserInfoFax MYINFO.ini D%X' *UserInfoOffice MYINFO.ini D%X' ,UserInfoAddress MYINFO.ini D%X' .UserInfoCity MYINFO.ini D%X' 0UserInfoState MYINFO.ini D%X' 2UserInfoZip MYINFO.ini D%X' 4UserInfoCO MYINFO.ini D%X' 6UserInfoDI MYINFO.ini D%X' 8UserInfoSEC MYINFO.ini D%X' :UserInfoUN MYINFO.ini D%X' <UserInfoWKR MYINFO.ini D%X' >UserInfo Boss Name MYINFO.ini D%X' @UserInfo Boss Title MYINFO.ini D%X' B Update Form with user info WorkerName D%vG workerName  DB@xj WorkerTitle D%vG WorkerTitle  DB@xjWorkerAreaCode D%vGWorkerAreaCode " DB@xj WorkerPhone D%vG WorkerPhone $ DB@xjWorkerExtension D%vGWorkerExtension & DB@xjFaxAC D%vGFaxAC ( DB@xj WorkerFax D%vG WorkerFax * DB@xj Countynumber D%vG Countynumber 6 DB@xjDistrict D%vGDIstrict 8 DB@xjSection D%vGSECtion : DB@xjUnit D%vGUNit < DB@xjWorker D%vGWorker > DB@xj CountyName D%vG CountyName , DB@xj CoAddress D%vG CoAddress . DB@xjCoCity D%vGCoCity 0 DB@xjCoState D%vGCoState 2 DB@xjCoZip D%vGCoZip 4 DB@xjSupervisorName D%vGSupervisorName @ DB@xjSupervisorTitle D%vGSupervisorTitle B DB@xj. Update other Form Fields on Form & Exit Macro- Selected$=GetFormResult$ ("CurrentDate")! TheSerialDate = Today() + 14$ TheDate$ = Date$(TheSerialDate)& SetFormResult "DueDate", TheDate$) EditGoTo "CreateDate" : UnlinkFields EditGoTo "GranteefirstName"- ToolsProtectDocument .NoReset = 1, .Type = 2/ ToolsProtectSection .Section = 2, .Protect = 0d FileClose 2 SelectName = - 1kpoh`(Attribute VB_Name = "MyInfo" Public Sub Main(X) D.nDescription|Enter Personal rma:zProcDataIInvoke _FuncINoi8l..nADim iRet B  User$ATitleAreaCod-PhonYourExtFax|AC Offic $AddressCitByStat Zip ODILSEB;UN WKRBoss|| 'DEFINE DIALOG BOX WordBasic.BeginDialog 582, 300,} G TextBox 109@ A 5@ 18@ I @ey 56 * 83 _[ 105WDi 2A3321A5r 34 _  | 9 7 @ 1$55E [1 Pi 23` 6i`cV3jFAXAC41e lV1@,CO629 *DI7m pV? UN6z4!l1.yVm23n`~64`'Fz7,, c3z#the followin`g infa@bout ys0elf. ", ׂ !:w5f"bC #1z0@8O$351{1A-ST- u5 abm3r13@? gY  ;"C O-DI-T-U,N-@H47224*; supervisor!a 124f6p6iOKButtY48 8pR21 fCanctel3kEndn ҂dlg!u! As Object: Se$t = CurValues. vGET USER INFO FROMI FILE AND@ PUT I NTOzx.t[GetPrivfileS@@ng$](" "'P:qMY.ini"r hl ? pa"4??>? Mpn_1r &.nAC `axU/-Y??>OMA\C$$a&gp Op | DIpp/-UN0 | {p y QaserInfo", "Boss Name`MYINFO.ini") dlgU.Title = WordBasic.[GetPrivateProfileString$]("t| 'DISPLAY DIALOG BOX AND RESPOTO USER INPUT iRet Dialog.p (If 3-1 Then 'OK BUTTON ?WRI@TE NEW3FO6I FILE xSx wYour ?, - -AreaCod|PhonEExtE@FaxACL+@OfficZ|Address0$ L+gCity ? : |StP  z Zo%  CoCity  ! CoStat$c b CoZip  "Supervi8sor<`, Boss! /Titl% b ' Upd. other  FieldsH on& t Macro Rem" SelA}ed$=G$ ("Curre8ntD9'`Serial = Today() + 14$5()lDure",a"GEditGoTo 0"Cre : Unlink'Grante@efirst3"ToolsProtDocum! .No@et`1, .Type@2/ .8= 2 `0 Else#FileClose D c.@- 1$nd #Sub ME(<<< <h ~ X%"  .@Pp &x  (((P X h]@'If document is protected, Unprotect it.GR ! cladd87 B@ilekPerform Spelling/Grammar check. (  !0 !( !B@X  ReProtect the document. ! cladd87 l B@koAttribute VB_Name = "Module1" Sub FormsSpellCheck2() Dim x As wdNo Then  9ZPassword:="c@ladd87E nd If'P(erf ing/Gramma8r clK.Op2tBs.vWi thFalse EachIn JsZx.Range.iof>$;;5AlwaysSuggest :=Tru; Next: 'Re the=&EW, n orese&, o:=wdAllowOnlyAbAAe55#xME (SLSS<N0{00020906-0000-0000-C000-000000000046}8(%HxAttribute VB_Name = "ThisDocument" Bas0{00020P906-0C$0046} |GlobalSpacFalse dCreatablPredeclaIdTru BExposeTemplateDerivBustomizD2as  *\G{000204EF-0000-0000-C000-000000000046}#4.0#9#C:\PROGRA~1\COMMON~1\MICROS~1\VBA\VBA6\VBE6.DLL#Visual Basic For Applications*\G{00020905-0000-0000-C000-000000000046}#_VBA_PROJECT:PROJECTyPROJECTwmVCompObjj8.2#0#C:\Program Files\Microsoft Office\Office10\MSWORD.OLB#Microsoft Word 10.0 Object Library*\G{00020430-0000-0000-C000-000000000046}#2.0#0#C:\WINDOWS\system32\stdole2.tlb#OLE Automation*\G{0D452EE1-E08F-101A-852E-02608C4D0BB4}#2.0#0#C:\WINDOWS\system32\FM20.DLL#Microsoft Forms 2.0 Object Library*\G{5926339E-587D-441B-9117-6D844445226A}#2.0#0#C:\TEMP\VBE\MSForms.EXD#Microsoft Forms 2.0 Object Library.E .`M &*\G{2DF8D04C-5BFA-101B-BDE5-00AA0044DE52}#2.2#0#C:\Program Files\Common Files\Microsoft Shared\Office10\MSO.DLL#Microsoft Office 8.0 Object Library  AB?5ThisDocument0<4b3dd31bThisDocument5% MyInfo0=4b3dd31b MyInfouM'Module1114b3dd3d7|Module1q0bP0^/?LOUP !Of+j@%-@S.H 0PQD0WordkVBAWin16~Win32MacVBA6#TemplateProjectEstdole`MSFormsCOfficeu ThisDocument< _EvaluateMyInfo@Main,iRet,pUserName\ UserTitleV9AreaCode UserPhoneYourExthLFaxACjYourFaxrN UserOffice0 UserAddressFUserCity UserStateUserZipDUserCOUserDIUserSEC4UserUN0UserWKR,BossNamef BossTitleH WordBasic BeginDialogFTextBoxQOKButton| CancelButton EndDialogmP dlgUserInfo2" CurValuesȤ UserDialogYourName;RGetPrivateProfileString$x YourTitleA# YourPhone YourOffice YourAddressYourCity YourStateYourZipYourCOYourDIYourSECvYourUNVYourWKRnDialogfSetPrivateProfileString=ExistingBookmark SetFormResultDocumentjModule1bFormsSpellCheck2gzxo FormFieldActiveDocument\ProtectionTypewdNoProtection Unprotect?PasswordOptionsCheckGrammarWithSpelling FormFields-|Range  NoProofing] CheckSpellingW AlwaysSuggestProtectfnoresetgwdAllowOnlyFormFields!l }6ID="{2ED02B8F-2A1D-4B91-B1EA-1DD4A525DAF8}" Document=ThisDocument/&H00000000 Module=MyInfo Module=Module1 Name="TemplateProject" HelpContextID="0" VersionCompatible32="393222000" CMG="C6C4D11D51251329132913291329" DPB="8C8E9B63A728A828A828" GC="525045A10AA20AA2F5" [Host Extender Info] &H00000001={3832D640-CF90-11CF-8E43-00A0C911005A};VBE;&H00000000 [Workspace] ThisDocument=0, 0, 0, 0, C MyInfo=0, 0, 0, 0, C ThisDocumentThisDocumentMyInfoMyInfoModule1Module1  FMicrosoft Word Document MSWordDocWord.Document.89q @ Bbjbj Z^"Z^"D}D}D}D}D}X}|}ކ|"<X}hjdΌΌΌΌΌ.lnnnnnn$mR-D}DΌΌDDD}D}ΌΌDDDDD}ΌD}ΌlDDlDDD}D}jtDΌ^ b$|}DD` Փ0DDDX}X}D}D}D}D}D}DDDDDDDDDX}X}$|}DX}X}|} FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT        FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTELNPRfhvxzƔȔʔޔ(*8:<PRTZ\^`tvĕjJ1hYqUj0hYqUjhYqUmHnHuj0hYqUjF/hYqUj.hYqUj-hYqUjT-hYqUj,hYqUj+hYqUhYqjhYqU3Ȕ:^֕ Hjܖ(Pxȗ@hWVUTSRQPOkNMLKJIHGFEDCBAĕƕԕ֕ؕ "68FHJ^`bfhjlЖҖԖؖ轸xmxj6hYqUjhYqUmHnHuj5hYqUj$5hYqUjhYq5UmHnHujn4hYq5U hYq5jhYq5Uj3hYqUj&3hYqUj2hYqUhYqjhYqUj1hYqU*ؖږܖޖ$&(*>@NPRfhvxzƗȗʗޗ ~j<hYqUUjz;hYqUj:hYqUj9hYqUj8hYqUj)8hYqUjhYqUmHnHuj7hYqUjUmHnHujA7U jUhYqjhYqU1XT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT     FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       .0>@BVXfhj~Ƞʠؠڠܠ(*,@BDHJLNbdflnprjAhYqUjhYqUmHnHuj@hYqUjw@hYqUj?hYqUjm?hYqUj>hYqUj >hYqUj=hYqUj<hYqUjhYqUhYq3hڠ*Lp ,PxȢ@Bjihgfedcba`_^]\[ZYXr¡֡ء "$(*,.BDFLNPRfhvxzƢȢʢjfGhYqUjGhYqUjeFhYqUjEhYqUjDhYqUjhYqUmHnHujUDhYqUjChYqUjChYqUjhYqUjpBhYqUhYq3ʢޢ.02<>BjyIhYqUjHhYqUjhYqUmHnHujhYqUjGhYqUhYq/ =!"#$%CareOf UppercaseUEnter the Addressee's Supplemental Address (Example: Suite or Apartment Number, C/O)Address1D CaseNumber Uppercase/Enter the Case Number (Example: V1234567A,B,C)D ClientCity UppercaseEnter the Addressee's City. ClientStateD ClientState Uppercase1Enter the Addressee's 2 digit State Abbreviation. ClientZipD ClientZip UppercaseKEnter the Addressee's Zip Code (+4 if known) (Example: 48909 or 48909-7537)D CoAddress UppercaseaEnter the County's mail address (street address, PO Box, etc., where the mail will be delivered).D CoAreaCodeEnter the County's Area CodeDCoCity UppercaseEnter the County's City.D CoExtensiond8(OJQJ_HmH sH tH XOX CaseNumber1?d8(OJQJ_HmH sH tH XOX ClientCity1@d8(OJQJ_HmH sH tH ZOZ ClientState1Ad8(OJQJ_HmH sH tH ZO"Z ClientZip1BdtCJOJQJ_HmH sH tH VO2V CoAddress1Cd8(OJQJ_HmH sH tH XOBX CoAreaCode1 Dd`CJOJQJ_HmH sH tH PORP CoCity1Ed8(OJQJ_HmH sH tH ZObZ CoExtension1Fd8(OJQJ_HmH sH tH ^Or^ CoPhoneNumber1Gd8(OJQJ_HmH sH tH ROR CoState1Hd8(OJQJ_HmH sH tH ^O^ CoSuppaddress1Id8(OJQJ_HmH sH tH XOX CountyName1Jd8(OJQJ_HmH sH tH \O\ CountyNumber1 Kd`CJOJQJ_HmH sH tH ROR CoZip1LdtCJOJQJ_HmH sH tH NON Date11 Md`CJOJQJ_HmH sH tH TOT District2 Nd`CJOJQJ_HmH sH tH LOL FaxAC Od`CJOJQJ_HmH sH tH VOV FirstName1Pd8(OJQJ_HmH sH tH XOX FirstName21Qd8(OJQJ_HmH sH tH `O"` GranteeAddress1 Rd`CJOJQJ_HmH sH tH \O2\ GranteeCareof Sd`CJOJQJ_HmH sH tH XOBX GranteeCity Td`CJOJQJ_HmH sH tH `OR` GranteeClientID Ud`CJOJQJ_HmH sH tH dObd GranteeFirstName2 Vd`CJOJQJ_HmH sH tH bOrb GranteeLastName1Wd8(OJQJ_HmH sH tH ZOZ GranteeState Xd`CJOJQJ_HmH sH tH VOV GranteeZip Yd`CJOJQJ_HmH sH tH TOT LastName1Zd8(OJQJ_HmH sH tH VOV LastName21[d8(OJQJ_HmH sH tH ROR OtherID1\d8(OJQJ_HmH sH tH ROR Section2 ]d`CJOJQJ_HmH sH tH ^O^ SuperAreaCode1 ^d`CJOJQJ_HmH sH tH `O` SuperExtension1_d8(OJQJ_HmH sH tH dOd SuperPhoneNumber1`d8(OJQJ_HmH sH tH `O` SupervisorName1ad8(OJQJ_HmH sH tH LO"L Unit2 bd`CJOJQJ_HmH sH tH PO2P Worker2 cd`CJOJQJ_HmH sH tH `OB` WorkerAreaCode1 dd`CJOJQJ_HmH sH tH bORb WorkerExtension1ed8(OJQJ_HmH sH tH TObT WorkerFax fd`CJOJQJ_HmH sH tH XOrX WorkerName1gd8(OJQJ_HmH sH tH \O\ WorkerName2hd8(5OJQJ_HmH sH tH ZOZ WorkerPhone1id8(OJQJ_HmH sH tH ^O^ WorkerTitle1jd8(5OJQJ_HmH sH tH LOL Emailkd8(OJQJ_HmH sH tH @0 0Address1BureauCareOf CaseNumber ClientCity ClientState ClientZip CoAddress CoAreaCodeCoCity CoExtension CoPhoneNumber CoState CoSuppaddress CountyName CountyNumberCoZipDate1DistrictEmail/FaxAC FirstName FirstName2GranteeAddress1 GranteeCareof GranteeCityGranteeClientIDGranteeFirstNameGranteeLastName GranteeState GranteeZipLastName LastName2OtherID Section! SuperAreaCode"SuperExtension#SuperPhoneNumber$SupervisorName%Unit&Worker'WorkerAreaCode(WorkerExtension) WorkerFax* WorkerName+ WorkerName2, WorkerPhone- WorkerTitle.0Address1BureauCareOf CaseNumber ClientCity ClientState ClientZip CoAddress CoAreaCodeCoCity CoExtension CoPhoneNumberCoState CoSuppaddress CountyName CountyNumberCoZipDate1DistrictFaxAC FirstName FirstName2GranteeAddress1 GranteeCareof GranteeCityGranteeClientIDGranteeFirstName1GranteeLastName GranteeState GranteeZipLastName LastName2OtherIDSection SuperAreaCodeSuperExtensionSuperPhoneNumberSupervisorNameUnitWorkerWorkerAreaCodeWorkerExtension WorkerFax WorkerName WorkerName2 WorkerPhone WorkerTitleUser Input 10pt(<Pdu$5I]n  4EYm(<Pdx mjLĕؖrʢB#(/8>LNORTUR  j6 n^f{|j +t}ȔhB !"$%&')*+,-.012345679:;<=DEMSB  &(4:<HNP\bdpsu"$035AGIU[]ilnz   ,24@CEQWYekmy"&(4:<HNP\bdpvxFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF0Address1BureauCareOf CaseNumber ClientCity ClientState ClientZip CoAddress CoAreaCodeCoCity CoExtension CoPhoneNumberCoState CoSuppaddress CountyName CountyNumberCoZipdate1DistrictEmailFaxAC FirstName FirstName2GranteeAddress1 GranteeCareOf GranteeCityGranteeClientIDGranteeFirstNameGranteeLastName GranteeState GranteeZipLastName LastName2OtherIDSection SuperAreaCodeSuperExtensionSuperPhoneNumberSupervisorNameUnitWorkerWorkerAreaCodeWorkerExtension WorkerFax WorkerName WorkerName2 WorkerPhone WorkerTitle)=Qev%6J^o !5FZn)=Qey  !"#$%&'()*+,-./';Oct#4H\m 3DXl';OcwYq@ z`(```UnknownGz Times New Roman5Symbol3& z Arial?5 z Courier New5& zaTahoma;Wingdings"h0@?Yq