ࡱ>   @ S bjbj 6?,ddddddd$P6P6P6PҢfds,6:9999:;E<LL%rrrrrr$uRcwrd@::@@rdd99spCpCpC@d9d9LpC@LpCpC:0D,ddpD 9ʤ ;O P6(@\D Els0sfD kx>@kx|DddddkxdD<M=pC=l?><<<rr! 0DZC 0NONRECURRING ADOPTION EXPENSES APPLICATION/ AGREEMENT FOR A CHILD WITHOUT SUPPORT SUBSIDY Michigan Department of Human Services See Directions on Page 2.IDENTIFYING INFORMATION (To be completed by adoption worker)SWSS Log NumberCase Number FORMTEXT       FORMTEXT      Child s Name Before Adoption (Last, First, Middle)Child s Name After Adoption (Last, First, Middle)Child s BirthdateSocial Security Number FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Adoptive Parent s Name (Last, First, Middle)Social Security Number FORMTEXT       FORMTEXT      Adoptive Parent s Name (Last, First, Middle)Social Security Number FORMTEXT       FORMTEXT      Adoptive Parent s Address (Number/Street, City, State, Zip Code)Phone FORMTEXT      ( FORMTEXT    )  FORMTEXT      Adoption Agency NamePhone FORMTEXT      ( FORMTEXT    )  FORMTEXT      Adoption Agency Address (Number/Street, City, State, Zip Code) FORMTEXT      Worker Name (Print)Worker SignatureDate FORMTEXT       FORMTEXT      SPECIAL NEEDS ELIGIBILITY INFORMATION (To be completed by adoption worker)Answer All Yes/No Questions1.Have all parental rights been terminated?1. FORMCHECKBOX  Yes FORMCHECKBOX  No2.Is the child a member of an American Indian tribe?2. FORMCHECKBOX  Yes FORMCHECKBOX  No3.Is the child under court jurisdiction as a result of an abuse and/or neglect proceeding?3. FORMCHECKBOX  Yes FORMCHECKBOX  No4.Has the Adoption been finalized by the court? If yes, date of finalization FORMTEXT      4. FORMCHECKBOX  Yes FORMCHECKBOX  No5a.Is the child SSI eligible? If yes, attach proof of current eligibility.5a. FORMCHECKBOX  Yes FORMCHECKBOX  No b.Is the child age 3 years or more? b. FORMCHECKBOX  Yes FORMCHECKBOX  No c.Does the child receive a foster care Determination of Care (DOC) rate Level 2 or higher? If yes, Attach the current DHS-470, 470A or 1945 DOC Assessment (dated within last six months), current Updated Service Plan (USP), and current signed professional documents documenting special needs (dated within last year). c. FORMCHECKBOX  Yes FORMCHECKBOX  No d.Is the child being adopted by a relative? d. FORMCHECKBOX  Yes FORMCHECKBOX  NoIf yes, Family Name FORMTEXT      Relationship FORMTEXT       e.Is the child being adopted by the parent of his/her previously adopted sibling? e. FORMCHECKBOX  Yes FORMCHECKBOX  NoIf yes, Sibling s adoptive Name FORMTEXT      Birthdate FORMTEXT       f.Is the child a member of a sibling group being adopted together at the same time with at least one sibling who has been approved for the Adoption Support Subsidy program as an individual? f. FORMCHECKBOX  Yes FORMCHECKBOX  NoIf yes, Sibling Name FORMTEXT      Birthdate FORMTEXT      6.Is the adoptive parent the birthparent of the child?6. FORMCHECKBOX  Yes FORMCHECKBOX  No7.Is the child a U.S. Citizen or qualified alien?7. FORMCHECKBOX  Yes FORMCHECKBOX  NoPARENT INFORMATION (To be completed by adoptive parent(s)) I am requesting a determination of eligibility for the Nonrecurring Adoption Expenses Program because I cannot adopt the child without Adoption Assistance. I understand if my child is eligible, this Agreement must be signed by me and the Department of Human Services (DHS) authorized agent prior to the final Order of Adoption date. I understand if my child is eligible, I must claim the expenses within two years after the final Order of Adoption date or sooner (see Claim/Reimbursement Process on page 2.) I understand reimbursement will be up to the maximum allowed by state policy for eligible expenses which cannot be reimbursed by any other source.Adoptive Parent Signature (Required)DateAdoptive Parent Signature (Required)DateELIGIBILITY DETERMINATION (To be completed by Adoption Subsidy Office)Child meets Special Needs Criteria above. FORMCHECKBOX Yes FORMCHECKBOX NoNonrecurring Adoption Expenses Eligibility FORMCHECKBOX Child Eligible FORMCHECKBOX Child IneligibleIneligibility Determination Based On FORMTEXT      Adoption Subsidy Specialist SignatureDateMDHS Authorized Agreement SignatureDate DIRECTIONSGENERAL INFORMATION The DHS-4814 is used for Nonrecurring Adoption Expenses (NRE) eligibility application/determination for a child without an adoption support subsidy, with no prior submission of a DHS-1341 Adoption Assistance Application. If determined eligible, the DHS-4814 is also used as the Agreement between DHS and the adoptive parent(s). Nonrecurring adoption expenses are reasonable and necessary fees, court costs, attorney fees and other expenses, directly related to the legal adoption of a special needs child, which cannot be reimbursed by any other source. The form must be signed by the adoptive parent(s) and the DHS authorized designee to enter into an agreement before the final Order of Adoption date.IDENTIFYING INFORMATION Adoption worker completes all information in this section. Adoption worker enters signature and date as verification of the information submitted on the form.ELIGIBILITY INFORMATION Adoption worker completes this section. Adoption worker checks applicable boxes, completes additional information as requested, and attaches required documentation. A child being adopted by a birth parent is not eligible for the NRE Program. PARENT INFORMATION Adoptive parent(s) completes this section. Adoptive parent(s) enters signature and date verifying a review and understanding of the information and requirements presented on the form. Parent(s) also signs to enter into a NRE agreement with DHS for an eligible child.ELIGIBILITY DETERMINATION Adoption Subsidy Office completes this section. 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Specialist checks eligible box or ineligible box, and enters an explanation if ineligible. Specialist enters signature and date verifying the eligibility determination. MDHS authorized designee signs and dates the form to enter into an agreement with the adoptive parent(s) of an eligible child for the NRE Program.CLAIM/REIMBURSEMENT PROCESS The adoptive parent(s) or a third party, with the adoption workers assistance, must claim expenses by submitting the DHS-4815 Parent Claim For Reimbursement of Nonrecurring Adoption Expenses, or the DHS-4816 Third Party Claim For Reimbursement of Nonrecurring Adoption Expenses, to the Adoption Subsidy Office within two years after the final Order Of Adoption date or sooner.APPEALS The Family may appeal a decision regarding the childs ineligibility for the Nonrecurring Adoption Expenses Program if they believe the decision is contrary to law or DHS policy. The Family shall submit a hearing request in writing within 90 days of the denial date or the adoptive placement date, whichever is later. A hearing request should be sent to the Adoption Subsidy Office, Attention: Hearings Coordinator, 235 S. Grand Ave, Suite 412, P.O. Box 30037, Lansing, MI 48909.THIS FORM IS TO BE SUBMITTED TO: Michigan Department of Human Services Adoption Subsidy Office 235 S. Grand Ave., Suite 412 P.O. Box 30037 Lansing, MI 48909AUTHORITY: 1939 PA 280 RESPONSE: Required. PENALTY: No reimbursement payment.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. DHS-4814 (Rev. 7-09) DISTRIBUTION: OriginalDHS Adoption Subsidy Office, All previous editions obsolete. MS Word CopiesAdoptive Family and Adoption Worker (before DHS processing) 1 CopiesAdoptive Family and Adoption Worker (after DHS processing) DHS-4814 (Rev. 7-09) All previous editions obsolete. 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VYof3=Zae1f4* /roPE Co7paY kC1p"daspY+ /% `aA- ( /G! ClearCas^eb51C0s`ub ) /b 6 ࢽ9 QNe wParaph5Nwа ag@&a-h@&? `? /St3 {,S>aÄ/0 Gra@nteS8aXH1$P,H5!+  countynumberG"ouƂy umbhr^2/#G : WorkerPhoneGrkC(Phn- 2FEFGranteeCitFyF CiyFFFCFCoExtens(ionC#C@CExns@#om_F C# c#AQ#lientStatQDjCl@ e@ t~D# E# c#OEL# ƍNam#5NmK 2U !M!ZipGBˀZHp!G !Q !KCb{!?%{!'1aIAreaCod2 A e`2ad2Co%-WPy>Ux2C&'U%UaseN$aweN஧&/S eFaxGeF@3xT2 ?!Q0RemoveRow#RAmvRw$#/q_0lastn 2#jls`n2$# a ]0`Firstt0FUrAtAae?$o? [P7ddress39dd":sq foY6S19Rb9`W9cg/0(B@JkG'B4Jk 9.2?M?(eL0( L$(Z5=cDistrictsD'/rpc`05=aCMInfoCreIf5=YRoA/1A..15=Qm%SectNi n2#__k_OtherIDGBOhrDTS __i_NoRese[% N0[st_TS _u5w_M4QJ|CoS _u_PrrArD4SW_y`s_,K[C*ss`,S _q\`+3G2W`ٴ2CoaBUa2 HiddeHpPp͓   {P#A#County"H(18$P,y:!0+CoCi`tyG Ci:2:#ނoareOfoareO|foo#o7iFaxACG axA 2 44Date1Ճ4D4tl1k4 4 44dModul55mdl2Ob@(MI\c5 :xMEH 8 " 0Unit  B@ oXPiAttribute VB_Name = "Unit" Public Sub MAIN() WordBasic.WW7_EditGoTo Destinat ion:=Endv \c5:xMEH 8 " 0cozip  B@oXPoAttribute VB_Name = "CoZip" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:="cDozEndx \c5:xMEH 8 " 0date1  B@oXPlAttribute VB_Name = "Date1" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:="dEndx \c5:FaxAC _CareOf nCoCity}County xMEH 8 " 0FaxAC  B@oXPjAttribute VB_Name = "FaxAC" Public Sub MAIN() WordBasic.WW7_EditGoTo Destina@tion:=Endx \c5:xMEH 8 " 0careof  B@oXPqAttribute VB_Name = "CareOf" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:="coEndz \c5:xMEH 8 " 0cocity  B@oXPpAttribute VB_Name = "CoCity" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:="cocEndz \c5y:xMEH 8 " 0county  B@oXPnAttribute VB_Name = "County" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:=""cEndz 5{:xMEHiddenqWorkerAddRowsqCorrect @p(Makes the selection hidden text (toggle):TemplateProject.Hidden.MAINh "10DF HJLN@PR0 ptT0 ptVXZ0bArial\^` B@BophxAttribute VB_Name = "Hidden" Public Sub MAIN(X) D.nDescription|Makes the selec,h text (toggle)Pro cDataWInvoke_FuncWTemplaTte"jV..JWordBasic.FormatFont Points:="10", Underline:=0, Color@:=9, SkeThrough SuperjFb<:=1mallCap1)ASpacinBg=0 pt>PosiKernMinTabd ArialBoldIIta End \c5:xMEH 8 " 0worker  B@oXPlAttribute VB_Name = "Worker" Public Sub MAIN() tdBasic.WW7_EditGoTo Destination:="wEndz {5q:xME @p+Adds row to table FOLLOWING cursor locationTemplateProject.AddRows.MAINh "0@ B@XP B@NoH@Attribute VB_Name = "AddRows" Public Sub MAIN() D.pDescription~s row to table FOLLOWING cursor loca\NProcDataZInvoke_FuncZTemplateA"ject..KWordBasic.LineDown 1 TInserBt Numt:D="Ends t{s5s:xME`  @2  " V*h    ]@Q This serves as a replacement to the spell checker within a protected documentCheck spelling now? %4'2 2 B@0 B@6 B@8@l B@>Hko0Attribute VB_Name = "Correct" Public Sub MAIN() Dim ans Rem This se@rves a replacement to the spell checker within @a proted docu3 ZWordBasic.MsgBox("C?King now ?", 3If4-1en  QATools4UnoDi %St`artOf"S7d>0Pg NoReset:=1, Type:=2 End If \c5u:xMEH CoStateModule1NoReset/OtherID'&8 "(8costate  B@oPHqAttribute VB_Name = "CoState" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:="cosEnd|       !"#$%'()*+,-./012346789:;<=>?@ABCEFGHJLNOPQRSTUVWXYZ[]^_`abcdefghijlmnopqrstuvwxy{|}~\5xME( wdNo Then  9ZPassword:="c@ladd87E nd If'P(erf ing/Gramma8r clK.Op2tBs.vWi thFalse EachIn JsZx.Range.iof>$;;5AlwaysSuggest :=Tru; Next: 'Re the=&EW, N oRese&, o:=wdAllowOnlyAbAAe\co5w:xMEH 8 " <H hx8 This saves as a form without resetting the form fields.@l B@>oAttribute VB_Name = "NoReset" Public Sub MAIN() Rem This saves a form without rztin g the4fields. WordBasic.ToolsProtectDocument ~:=1, Ty pe:=2End \c5i:xMEH 8 "(8otherid  B@0oPHsAttribute VB_Name = "OtherID" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:=$"oidEnd| \c5k:xSection5__SRP_0"__SRP_1D&__SRP_2ITMEH 8 "(8Section  B@oPHjAttribute VB_Name = "Section" Public Sub MAIN() WordBasic.WW7_EditGoTo Desti$nar:=End| rU K*srU~~~~~~~~k cE$ % >  : Ia  q1Y!Iq 1Y!Aa!Aa!9Qi !9Q TemplateProject ThisDocumentSuperPhoneNumberUnitGranteeFirstNameWorkerExtensionGranteeLastNameGranteeClientIDGranteeAddress1AddChildInfoRowWorkerAreaCodeSupervisorNameSuperExtentionAddSvcReferral SvcRefHeading SuperAreaCode GranteeCareof CoSuppaddress CoPhoneNumber ClearCaseInfoCounty NewParagraph GranteeState countynumber WorkerPhone GranteeCity CoExtension ClientState WorkerName GranteeZip CountyName CoAreaCode ClientCity CaseNumber WorkerFax RemoveRow lastname2 FirstName CoAddress ClientZipRowBreakLastNameDistrictCaseInfoAddress1SectionOtherIDNoResetCoStateCorrectAddRowsWorkerCoZipHiddenVBACoCityCareOfFaxACDate1F /C:\PROGRA~1\COMMON~1\MICROS~1\VBA\VBA6\VBE6.DLL i 0 F5C:\Program Files\Microsoft Office\Office10\MSWORD.OLBWord Q y @0FC:\WINDOWS\system32\stdole2.tlbstdole a  P.E .`M C:\WINDOWS\system32\FM20.DLLMSForms A A i `QUNGI 2C:\DOCUME~1\MARTIN~1\LOCALS~1\Temp\VBE\MSForms.exd a A  pL-[DR?C:\Program Files\Common Files\Microsoft Shared\Office10\MSO.DLLOffice Q y MAIN Module1(     "- !#*$%&'()+4,.A/01235<6789:;=F>?@BpCDEGjHIJgLMNOPQRSTUVWXYZ[\]^_`abcdefhikslmnoqrtuvwxyz{|}~trU~| krU $`n\c5m:x__SRP_3KgAddress1MCaseInfo!District#\MEH 8 "(8Address1  B@```oPHnAttribute VB_Name = "Address1" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:"= End~ \c5a:xMES5o:xME @`bEnter Personal InformationTTemplateProject.CaseInfo.MAINx@ ``PppP@@PpP``PPE PPP@ e` mPc " (08@HPX `"& (&0(X&(&&& $H Np*,* .P*,44.P   <FHXFJF8HLLHh 2 & FHHFJ Fp H L LP H " B DX B F B0 Dx H H DP " 6 : B8>6:N8NB 4 X` p ]]]]]]]]0]H]`]xOPEN FCTPSA TOOLBAR B@ FCTPSA Tools B@@DEFINE DIALOG BOXF,CaseInfo B@  YourFCCNo B@8 YourFCCN B@P  YourFCWLNo B@i YourFCWN B@  YourPSCNo B@ YourPSCN B@fYourHAL B@XfYourHAF B@ fYourDC B@k  0Enter the following information about this case. B@d# FC Case No.: B@d; FC Case Name: B@dܥoR FC Load No.: B@do k FC Worker Name: B@d PS Case No.: B@d PS Case Name: B@d8 Household Ass'd Last: B@d  Household Ass'd First: B@d  Date Completed: B@d ,X B@ B@ ]F !!.6GET USER INFO FROM INI FILE AND PUT IT INTO DIALOG BOX$UserInfoFCCaseNoC:\Windows\CaseInfo.ini %  ( UserInfo FCCaseNameC:\Windows\CaseInfo.ini %  (UserInfoFCLoadNoC:\Windows\CaseInfo.ini %  (UserInfo FCWorkerNameC:\Windows\CaseInfo.ini %  (nUserInfoPSCaseNoC:\Windows\CaseInfo.ini %  (UserInfo PSCaseNameC:\Windows\CaseInfo.ini %  (UserInfo HouseholdLastC:\Windows\CaseInfo.ini %  (UserInfoHouseholdFirstC:\Windows\CaseInfo.ini %  (UserInfo DCompletedC:\Windows\CaseInfo.ini %  (,DISPLAY DIALOG BOX AND RESPOND TO USER INPUT  !%'  OK BUTTON WRITE NEW USER INFO IN INI FILE UserInfoFCCaseNo ! C:\Windows\CaseInfo.ini B@  UserInfo FCCaseName !C:\Windows\CaseInfo.ini B@ UserInfoFCLoadNo !C:\Windows\CaseInfo.ini B@ UserInfo FCWorkerName !C:\Windows\CaseInfo.ini B@ 2UserInfoPSCaseNo !C:\Windows\CaseInfo.ini B@ UserInfo PSCaseName !C:\Windows\CaseInfo.ini B@ UserInfo HouseholdLast !C:\Windows\CaseInfo.ini B@ jUserInfoHouseholdFirst !C:\Windows\CaseInfo.ini B@ ~UserInfo DCompleted !C:\Windows\CaseInfo.ini B@ Get user info from INI fileUserInfoFCCaseNoC:\Windows\CaseInfo.ini % ' UserInfo FCCaseNameC:\Windows\CaseInfo.ini % ' UserInfoFCLoadNoC:\Windows\CaseInfo.ini % ' UserInfo FCWorkerNameC:\Windows\CaseInfo.ini % ' UserInfoPSCaseNoC:\Windows\CaseInfo.ini % '  UserInfo PSCaseNameC:\Windows\CaseInfo.ini % ' 8 UserInfo HouseholdLastC:\Windows\CaseInfo.ini % ' UserInfoHouseholdFirstC:\Windows\CaseInfo.ini % ' UserInfo DCompletedC:\Windows\CaseInfo.ini % ' 2 Update Form with user info<FCCASENO %"GFCCASENO  B@$j FCCASENAME %"G FCCASENAME  B@$jZFCWORKERLOADNO %"GFCWORKERLOADNO  B@$jl FCWORKERNAME %"G FCWORKERNAME  B@$jPSCASENO %"GPSCASENO  B@$j PSCASENAME %"G PSCASENAME  B@$jHOUSEHOLDASSESSEDLST %"GHOUSEHOLDASSESSEDLST  B@$jHOUSEHOLDASSESSEDFST %"GHOUSEHOLDASSESSEDFST  B@$j DATECOMPLETED %"G DATECOMPLETED  B@$j. Update other Form Fields on Form & Exit Macrod B@&'kxophmAttribute VB_Name = "CaseInfo" Public Sub MAI`N() D.rDescriptionEnter Personal rma:zProcDataIInvoke_FuncITemplateA"ject..yLDim iRet  UserFCCNo$ I WL WNPS HALFDCSelU 'OPEN FCTPSA TOOLBAR WordBasic.ViewToolbars ColorButtons:=1, Large0, Tipc"':=";/s", Show+'DEFINE DIALOG BOXBeginDialog 582, 30 Ʌ 1Text@Box 15 3 265, 18, "Youdka 56,  8/ wW 7@ 10ˀ& N13]\ 5A  2AY1y510QO 24 F i24 $DC@ 4 1079` 4B3;c|the following info} about this c. 19K$,1 FC | No.:w5p!YLoad #Y^k{x 1` PS} ,5,3 1 93(Household AsHs'd`st2B;FirD`eted3IOKc26% 821 EndÏdlgA Oba: SHet I= GCurValues.! GET USER INF@O FROM I FILE AND PUT I@NTO .@G[GetPrivfileSng$]("\NoaC:\Windows\!.ini" p H?u $T???C5?u?oNCp`9Q9_er"\OON OOjS##2bdaDLastooegHAF???KϒGOOHDC??>DCoKCDISPLAYAbCRESPOCPCED * HHIf(x>P?If0-1 Then 'OK BUTTONWRITE NEWXLIN6LYTQH`zHeB,G~OJo<O e4:CN;&HM_R] GW % GEo k SGO"qrA GL >FFFDCr fromr?cqfD)dC:("UserInfo", "FC CaseNXC:\Windows\P.ini"p) N$ = WordBasic.[GetPrivateProfileString$]1amev"jWLNo5lLoad(ՆWjkerNkPSC5k)ց4#'5HALsHouseholdLastdHAF<HFirfDC3DCompleted5 ' Upd Form with @Er &iIfExistBook mark(AASENO") ThDen SetR`esult ,2 yo$_ G AME CC A WORKERLOAD N'f N?!@j#/]4# ?$_ "H HOUSEHOLDASSE@DLST^B_#AnF"F?!DATECOMPLETo Attribute VB_Name = "RemoveRow" Public Sub MAIN() WordBasic.ToolsUnprotectDocument BableS\el<2Dt oYP W NoReset:=1, Type:=2 End \c5Q:xMEH 8 "(8 WorkerFax  B@ oPHmAttribute VB_Name = "WorkerFax" Public Sub MA@IN() dBasic.WW7_EditGoTo Destination:= End \c5S:CaseNumberClientCity(*CoAreaCodeCountyName)-xMEH 8 "(8 casenumber  B@oPHuAttribute VB_Name = "CaseNumber" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:="cnEnd \c5U:      !"$%&'()*+,-./013456789:;<=>?@BCDEFGHIJKLMNOQRSTUVWXYZ[\]^`abcdefghijklmopqrstuvwxyz{|~xMEH 8 "(8 clientcity  B@oPHuAttribute VB_Name = "ClientCity" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:="ccEnd \c5W:xMEH 8 "(8 coareacode  B@oPHxAttribute VB_Name = "CoAreaCode" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:="coa"cEnd \c5I:xMEH 8 "(8 countyname  B@oPHuAttribute VB_Name = "Countyh" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:=4"cnEnd \c5K:xMEGranteeZip#WorkerName,.2ClientStateACoExtension+7PH 8 "(8 GranteeZip  B@oPHpAttribute VB_Name = "GranteeZip" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:= End \c5M:xMEH 8 "(8 workername  B@oPHtAttribute VB_Name = "Workerh" Public Sub MAIN() dBasic.WW7_EditGoTo Destination:="wnEnd \c5O:xMEH 8 "(8 clientstate  B@oPHvAttribute VB_Name = "ClientState" Public Sub MAIN() WordBasic.WW7_EditGoTo Destinati@on:="csEnd \c5A:xMEH 8 "(8 coextension  B@oPHtAttribute VB_Name = "CoExtension" Public Sub MAIN() WordBasic.WW7_EditGoTo Destinatr@:="coeEnd \c5C:GranteeCity_WorkerPhone02ncountynumber}GranteeState15xMEH 8 "(8 GranteeCity  B@oPHqAttribute VB_Name = "GranteeCity" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:= End \c5E:xMEH 8 "(8 workerphone  B@:oPHuAttribute VB_Name = "WorkerPhone" Public Sub MAIN() dBasic.WW7_EditGoTo DestinationP:="wpEnd \c5G:xMEH 8 "(8 Countynumber  B@ oPHtAttribute VB_Name = "countynumber" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:="C End \c55xMEH 8 "(8 GranteeState  B@oPHrAttribute VB_Name = "GranteeState" Public Sub MAIN() WordBasic.WW7_EditGoTo Destinat ion:= End \c55xMENewParagraph^ThisDocument46_VBA_PROJECTK 7ClearCaseInfo3;VH 8 " (@`px B@ B@0 $ B@:@l B@>O B@^oŰAttribute VB_Name = "NewParagraph" Public Sub MAIN() WordBasic.ScreenUpdating 0 >ToolsUnprotectDo@cument Insert Chr(13[?P = NoReset:=1, Type:=2 QCharRight 1 End 55#xME (SLSS<N0{00020906-0000-0000-C000-000000000046}8(%HxAttribute VB_Name = "ThisDocument" Bas0{00020P906-0C$0046} |GlobalSpacFalse dCreatablPredeclaIdTru BExposeTemplateDerivBustomizD2\c55xas  *\G{000204EF-0000-0000-C000-000000000046}#4.0#9#C:\PROGRA~1\COMMON~1\MICROS~1\VBA\VBA6\VBE6.DLL#Visual Basic For Applications*\G{00020905-0000-0000-C000-000000000046}#8.2#0#C:\Program Files\Microsoft Office\Office10\MSWORD.OLB#Microsoft Word 10.0 Object Library*\G{00020430-0000-0000-C000-000000000046}#2.0#0#C:\WINDOWS\system32\stdole2.tlb#OLE Automation*\G{0D452EE1-E08F-101A-852E-02608C4D0BB4}#2.0#0#C:\WINDOWS\system32\FM20.DLL#Microsoft Forms 2.0 Object Library *\G{55F5DC51-A591-4EF5-A2E0-13479ADE490E}#2.0#0#C:\DOCUME~1\MARTIN~1\LOCALS~1\Temp\VBE\MSForms.exd#Microsoft Forms 2.0 Object Library.E .`M &*\G{2DF8D04C-5BFA-101B-BDE5-00AA0044DE52}#2.2#0#C:\Program Files\Common Files\Microsoft Shared\Office10\MSO.DLL#Microsoft Office 8.0 Object Library:  ^"9"! *)('&%$#210/.-,+9865435:ThisDocument1C4befd79aThisDocument5% SuperPhoneNumber1D4befd79a SuperPhoneNumber5%Unit1E4befd79a"Unit :0 GranteeFirstName1F4befd79a$ GranteeFirstName5H%WorkerExtension1G4befd79a&WorkerExtension5`%GranteeLastName1H4befd79a(GranteeLastName5x%GranteeClientID1I4befd79a*GranteeClientID5%GranteeAddress11J4befd79a,GranteeAddress15%AddChildInfoRow224befd7a7.AddChildInfoRow5|7WorkerAreaCode1L4befd79aBWorkerAreaCode5SupervisorName1M4befd79aDSupervisorName5SuperExtention1N4befd79aFSuperExtention5AddSvcReferral1O4befd79aHAddSvcReferral5 SvcRefHeading1P4befd79aJSvcRefHeading58 SuperAreaCode1Q4befd79adSuperAreaCode5PGranteeCareof1R4befd79afGranteeCareof5hCoSuppaddress1S4befd79ahCoSuppaddress5CoPhoneNumber1T4befd79ajCoPhoneNumber5ClearCaseInfo1U4befd79alClearCaseInfo5 NewParagraph1V4befd79aNewParagraph5GranteeState1W4befd79aGranteeState5countynumber1X4befd79acountynumberG:WorkerPhone1Y4befd79aWorkerPhoneE:GranteeCity1Z4befd79aGranteeCityC:(CoExtension1[4befd79aCoExtensionA:@ClientState1]4befd79aClientStateO:XWorkerName1^4befd79aWorkerNameM:pGranteeZip1_4befd79aGranteeZipK:CountyName1`4befd79aCountyNameI:CoAreaCode1a4befd79aCoAreaCodeW:ClientCity1b4befd79aClientCityU:CaseNumber1c4befd79aCaseNumberS:WorkerFax1d4befd79aWorkerFaxQ:RemoveRow1e4befd79aRemoveRow_:qlastname21f4befd79alastname2]:0FirstName1g4befd79aFirstName[:HCoAddress1h4befd79aCoAddressY:`ClientZip1i4befd79aClientZipg:xRowBreak1j4befd79aRowBreake:MLastName1k4befd79aLastNamec:District1l4befd79aDistricta: CaseInfo1m4befd79aCaseInfoo:Y Address11n4befd79a(Address1m: Section1o4befd79a*Sectionk: OtherID1p4befd79a,OtherIDi:  NoReset1q4befd79a@NoResetw:8uCoState1r4befd79a.CoStateu:PCorrect1s4befd79a0Corrects:hyAddRows1t4befd79a:AddRowsq: Worker1u4befd79a< Worker: CoZip1v4befd79a> CoZip: Hidden1w4befd79a@ Hidden{: County1x4befd79ab Countyy: CoCity1y4befd79ad CoCity: CareOf1z4befd79af CareOf: FaxAC204befd79ah FaxAC:( Date1214befd79aj Date1:@Module1244befd82dnModule1Xbx( `0x8@hP08H@( Xxv I' iK@.U:IJK |P@պ@; s[ۭCJAmF` BX &$+Κ`GZpuxJnA-qE; {.}2Kg髒q%dCQ]fltE_@K4ƽgO=Y@$F/=WiPOJolSHNDW2Oy'O+F1!y(I.ZN:*8ecSDӴ:%]N"QoadLL &jNdiNI~ [I! }%@,5\oBBTR,zPXN#VDq'F[^zs(nzHMNgGK.|LюdQy @e&&Dp%F;l֑F8N)!y# iCUO6W]G+x3ه/HcI@ԴO{<mAӋl_M NVnoʳ@9vMt E)φZx  Id6R+z6If?D`EZ3mCRjH4BN]uC0&D'e(JpA 1ZE@ ºQlc8yG8J'j(CWordkVBAWin16~Win32MacVBA6#TemplateProjectEstdole`MSFormsCOfficeu ThisDocument< _EvaluateSuperPhoneNumber\MAIN, WordBasic WW7_EditGoTod DestinationлUnitGranteeFirstNameEWorkerExtensionGranteeLastName.GranteeClientIDGranteeAddress1AddChildInfoRow^ToolsUnprotectDocument(NextCellWW7_EditAutoTextCContextXnInsertAsInsertrCharLeftToolsProtectDocument-0NoResetgWorkerAreaCodeSupervisorNameSuperExtentionAddSvcReferral} SvcRefHeadingi&TableSelectRowTableInsertRowQNumRows CenterParaLineUpK InsertPara,LineDownxTableInsertCells ShiftCells( CharRightPTableMergeCellst BorderRight_ SuperAreaCodeq GranteeCareof CoSuppaddress^  CoPhoneNumberx ClearCaseInfohFileFind SearchName֡ SearchPath.SubDir+Title~AuthorKeywordsTSubjectRPOptions MatchCase PatternMatch DateSavedFromu= DateSavedTojdSavedByDateCreatedFrom DateCreatedToViewISortByoListBy+ SelectedFile\Kill NewParagraphqScreenUpdating! ChrK~ GranteeStateM countynumberyx WorkerPhone GranteeCity@ CoExtensionK ClientState WorkerNameJ GranteeZip  CountyName CoAreaCode ClientCitym CaseNumberA WorkerFaxv RemoveRow0^TableDeleteRowA lastname2sL FirstName CoAddress ClientZipRowBreakFTableRowHeight"X RulerStyleaLineSpacingRulep LineSpacing LeftIndenti AlignmentI AllowRowSplit{LastNameDistrict}-CaseInfoiRet,p UserFCCNoBUserFCCN7 UserFCWLNoyUserFCWN UserPSCNoOUserPSCNqUserHALօUserHAFЅUserDC SelectNameW; ViewToolbars| ColorButtons} LargeButtonsSWToolTips5+Toolbar2Show BeginDialogFTextBoxQOKButton| EndDialogmP dlgUserInfo2" CurValuesȤ UserDialog YourFCCNo+GetPrivateProfileString$xYourFCCN. YourFCWLNoYourFCWN0 YourPSCNo9YourPSCNP<YourHALYYourHAFYYourDCDialogfSetPrivateProfileString=ExistingBookmark SetFormResult FileClose_Address1OSectionGOtherIDCoState1Correct'ansxtMsgBoxRStartOfDocument ToolsSpellingAddRowsWorker8CoZip0Hidden] FormatFont&Points UnderlineColor2F StrikeThrough" Superscript SubscriptV SmallCaps~cAllCapss_SpacingSPositionKerningB KerningMin1FontUBoldItalic!CountyG8CoCityr7CareOfƻFaxACjDate11DocumentjModule1bFormsSpellCheck2gzxo FormFieldActiveDocument\ProtectionTypewdNoProtection Unprotect?PasswordCheckGrammarWithSpelling FormFields-|Range  NoProofing] CheckSpellingW AlwaysSuggestProtectfwdAllowOnlyFormFields!   # %')+-/)*++-,/.1/;0=1?2A-C E !G "I #K $A3%c42e&g1i3k4m5e56g67i78k89o9l:LOPQRSTUVWXY Z!["\#^$_%`&a'b(j)k;MEH 8 "&  p c:\windows\r caseinfo.initvxz|~d B@n8ac:\windows\caseinfo.ini B@0oH@EAttribute VB_Name = "ClearCaseInfo" Public Sub MAIN() WordBasic.File@Find Slch:=" ",! Path c:\wJows\4Jceie.ini0ubDir:=0, Title6Autho" Keywysject Option=`MatchKex#ternDateSavedFrom# LToByC?@ABCDEFHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklnopqrstuvwxyz{}~\c55xMEH 8 " (8 superareacode  B@oPH}Attribute VB_Name = "SuperAreaCode" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:="sacEnd \c 55SvcRefHeading AddSvcReferral<>Gs SuperExtentionmSupervisorName=C|xMEH ?8@ "  (@2P  2  2 P ` p2   2  0 @2P   2   2  X h2x   4  ( 84H     0 HXh4x 4( B@0 B@LP B@N B@< asvcrefh168: B@4x B@R+ B@2/svcrefh268: B@4 B@T B@R B@26svcrefh368: B@4SvcR B@R6 B@V: B@2svcrefh468: B@4: B@R B@V B@2svcrefh568: B@4 B@R B@V B@2svcrefh668: B@4 B@R B@V B@2svcrefh768: B@4 B@R B@V B@2svcrefh868: B@4 B@R B@2svcrefh968: B@4 B@R B@V B@2 svcrefh1068: B@4 B@R B@V B@2 svcrefh1168: B@4 B@R B@VAdd Instruction Row B@X\ B@Z B@< B@^ B@` B@2  B@^ B@` B@b B@< SvcRefH1268: B@4 B@2 svcrefH1368: B@4@l B@>oAttribute VB_Name = "SvcRefHeading" Public Sub MAIN() WordBasic.ToolsUnprotectDocu@ment Ba@bleSeloAttribute VB_Name = "AddSvcReferral" Public Sub MAIN(X) ".~Descriptions a row and fields for A. Ser`vice ePProcData\Invoke_Func\Template"ject. . WordBasic.ToolsU nprot2Document NextCell WW7_EditAutoT" :="F1", Cont :=1, InsertAs:=0 <22a23?YmK4?5?f6?_27?8 u_X.?9 1^0 ~t CharLeft p45 i @NoRese, Type:=2 E \c55xMEH 8 " (8superextension  B@oPH|Attribute VB_Name = "SuperExtention" Public Sub MAIN() WordBasic.WW7_EditGoTo DestinBar:="sesEnd \c55xMEH 8 " (8supervisorname  B@oPH{Attribute VB_Name = "Supervisor" Public Sub MAIN() WordBasic.WW7_EditGoTo Destinati@on:="snCEnd \c55xMEWorkerAreaCodeAddChildInfoRow @BGranteeAddress1 GranteeClientID AEH 8 " (8workerareacode  B@oPH|Attribute VB_Name = "WorkerAreaCode" Public Sub MAIN() dBasic.WW7_EditGoTo Destination:="wacEnd v55xME(6 << <x `.p%H@^"9$*\Rffff*224befd7a7 "  4( `4p 4 4 84H 4 4 @P B@0efirst B@2B@ ChildInfo168: B@4 B@2 ChildInfo268: B@41& B@2-][ ChildInfo368: B@4y. B@2t ChildInfo468: B@4 B@2 ChildInfo568: B@4 B@2 ChildInfo668: B@4 B@2 ChildInfo768: B@4 B@<@l B@>oAttribute VB_Name = "AddChildInfoRow" Public Sub MAIN () WordBasic.ToolsUnprotectDocument BNextCell &WW7_EditAutoT" :="1"@, Cont:=0, InsertAs :=1U>f2c33c34c3567CharLeft( 30RP N@oReset, Type:=2 EndA \c55xMEH 8 ""0@GranteeAddress1  B@temoH@uAttribute VB_Name = "GranteeAddress1" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:=End \c55xMEH 8 ""0@GranteeClientID  B@ficoH@uAttribute VB_Name = "GranteeClientID" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:=End \c55GranteeLastName WorkerExtension DFGranteeFirstName"GSuperPhoneNumber"xMEH 8 ""0@granteelastname  B@svcoH@~Attribute VB_Name = "GranteeLast" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:="glnEnd \c55xMEH 8 ""0@workerextension  B@oH@xAttribute VB_Name = "WorkerExtension" Public Sub MAIN() dBasic.WW7_EditGoTo DestinaBtr:="weEnd \c55xME      !"#$%&'()*+,-./0123456789:;<=>?@BCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_aH 8 ""0@granteefirstname  B@PoH@Attribute VB_Name = "GranteeFirstL" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:="g5fnEnd \c55xMEH 8 ""0@superphonenumber  B@oH@Attribute VB_Name = "SuperPhoneNumber" Public Sub MAIN() WordBasic.WW7_EditGoTo Destination:="spnEnd ID="{92B471A1-F779-4EBB-9BF4-19686794CB56}" Document=ThisDocument/&H00000000 Module=SuperPhoneNumber Module=GranteeFirstName Module=WorkerExtension Module=GranteeLastName Module=GranteeClientID Module=GranteeAddress1 Module=AddChildInfoRow Module=WorkerAreaCode Module=SupervisorName Module=SuperExtention Module=AddSvcReferral Module=SvcRefHeading Module=SuperAreaCode PROJECTI PROJECTwmACompObj`j Module=GranteeCareof Module=CoSuppaddress Module=CoPhoneNumber Module=ClearCaseInfo Module=NewParagraph Module=GranteeState Module=countynumber Module=WorkerPhone Module=GranteeCity Module=CoExtension Module=ClientState Module=WorkerName Module=GranteeZip Module=CountyName Module=CoAreaCode Module=ClientCity Module=CaseNumber Module=WorkerFax Module=RemoveRow Module=lastname2 Module=FirstName Module=CoAddress Module=ClientZip Module=RowBreak Module=LastName Module=District Module=CaseInfo Module=Address1 Module=Section Module=OtherID Module=NoReset Module=CoState Module=Correct Module=AddRows Module=Worker Module=Hidden Module=County Module=CoCity Module=CareOf Module=FaxAC Module=Date1 Module=CoZip Module=Unit Module=Module1 Name="TemplateProject" HelpContextID="0" VersionCompatible32="393222000" CMG="1210FAEA08EE08EE08EE08EE" DPB="2426CC1CCC2FCD2FCD2F" GC="3634DE0EE232F533F5330A" [Host Extender Info] &H00000001={3832D640-CF90-11CF-8E43-00A0C911005A};VBE;&H00000000 [Workspace] ThisDocument=0, 0, 0, 0, C SuperPhoneNumber=0, 0, 0, 0, C GranteeFirstName=0, 0, 0, 0, C WorkerExtension=0, 0, 0, 0, C GranteeLastName=0, 0, 0, 0, C GranteeClientID=0, 0, 0, 0, C GranteeAddress1=0, 0, 0, 0, C AddChildInfoRow=0, 0, 0, 0, C WorkerAreaCode=0, 0, 0, 0, C SupervisorName=0, 0, 0, 0, C SuperExtention=0, 0, 0, 0, C AddSvcReferral=0, 0, 0, 0, C SvcRefHeading=0, 0, 0, 0, C SuperAreaCode=0, 0, 0, 0, C GranteeCareof=0, 0, 0, 0, C CoSuppaddress=0, 0, 0, 0, C CoPhoneNumber=0, 0, 0, 0, C ClearCaseInfo=0, 0, 0, 0, C NewParagraph=0, 0, 0, 0, C GranteeState=0, 0, 0, 0, C countynumber=0, 0, 0, 0, C WorkerPhone=0, 0, 0, 0, C GranteeCity=0, 0, 0, 0, C CoExtension=0, 0, 0, 0, C ClientState=0, 0, 0, 0, C WorkerName=0, 0, 0, 0, C GranteeZip=0, 0, 0, 0, C CountyName=0, 0, 0, 0, C CoAreaCode=0, 0, 0, 0, C ClientCity=0, 0, 0, 0, C CaseNumber=0, 0, 0, 0, C WorkerFax=0, 0, 0, 0, C RemoveRow=0, 0, 0, 0, C lastname2=0, 0, 0, 0, C FirstName=0, 0, 0, 0, C CoAddress=0, 0, 0, 0, C ClientZip=0, 0, 0, 0, C RowBreak=0, 0, 0, 0, C LastName=0, 0, 0, 0, C District=0, 0, 0, 0, C CaseInfo=0, 0, 0, 0, C Address1=0, 0, 0, 0, C Section=0, 0, 0, 0, C OtherID=0, 0, 0, 0, C NoReset=0, 0, 0, 0, C CoState=0, 0, 0, 0, C Correct=0, 0, 0, 0, C AddRows=0, 0, 0, 0, C Worker=0, 0, 0, 0, C Hidden=0, 0, 0, 0, C County=0, 0, 0, 0, C CoCity=0, 0, 0, 0, C CareOf=0, 0, 0, 0, C FaxAC=0, 0, 0, 0, C Date1=0, 0, 0, 0, C CoZip=0, 0, 0, 0, C Unit=0, 0, 0, 0, C Module1=0, 0, 0, 0, C ThisDocumentThisDocumentSuperPhoneNumberSuperPhoneNumberGranteeFirstNameGranteeFirstNameWorkerExtensionWorkerExtensionGranteeLastNameGranteeLastNameGranteeClientIDGranteeClientIDGranteeAddress1GranteeAddress1AddChildInfoRowAddChildInfoRowWorkerAreaCodeWorkerAreaCodeSupervisorNameSupervisorNameSuperExtentionSuperExtentionAddSvcReferralAddSvcReferralSvcRefHeadingSvcRefHeadingSuperAreaCodeSuperAreaCodeGranteeCareofGranteeCareofCoSuppaddressCoSuppaddressCoPhoneNumberCoPhoneNumberClearCaseInfoClearCaseInfoNewParagraphNewParagraphGranteeStateGranteeStatecountynumbercountynumberWorkerPhoneWorkerPhoneGranteeCityGranteeCityCoExtensionCoExtensionClientStateClientStateWorkerNameWorkerNameGranteeZipGranteeZipCountyNameCountyNameCoAreaCodeCoAreaCodeClientCityClientCityCaseNumberCaseNumberWorkerFaxWorkerFaxRemoveRowRemoveRowlastname2lastname2FirstNameFirstNameCoAddressCoAddressClientZipClientZipRowBreakRowBreakLastNameLastNameDistrictDistrictCaseInfoCaseInfoAddress1Address1SectionSectionOtherIDOtherIDNoResetNoResetCoStateCoStateCorrectCorrectAddRowsAddRowsWorkerWorkerHiddenHiddenCountyCountyCoCityCoCityCareOfCareOfFaxACFaxACDate1Date1CoZipCoZipUnitUnitModule1Module1 @ bjbj xP"xP"ϚϚϚϚϚҢҢfdQ,֤R(((((,T|Э$}Rϲޮ-Ϛ((ޮϚϚ(( Ϛ(Ϛ(ϚϚٟ5(ʤ ;O  !0QϲϲϚϚϚϚϲϚޮޮ$ 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        FORMTEXT &(*>@BLNPRfhjtvxzĬƬȬʬެ(yj>Hh*UjJGh*Ujh*5UmHnHujFh*5U h*5jh*5UjEh*UjDh*Ujh*UmHnHujbCh*Ujh*UjBh*Uh*,(*8:<PRTZ\^`tvĭƭȭҭԭ֭ح "68:>@BDXZhjjNh*UjMh*UjMh*UjLh*UjKh*UjJh*UjxJh*Ujh*UmHnHujIh*Uh*jh*UjHh*U1jlʮ̮ήخڮܮޮ "$8:<FHJL`bdnprѾѳɥњɥяɥфɥyɥjSh*UjRRh*UjQh*Uj,Qh*Ujh*UmHnHujrPh*UjOh*Ujh*Uh*jh*5UmHnHuj Oh*5U h*5jh*5U/ܮ"Jr¯:bԺ$Fj&edXWVUcSRQPONjLKJIHGFbDCrt¯įدگܯ(*,68:<PR`bdxz|·j~[h*UjZh*UjZh*UjXh*Uj>Xh*UUjvWh*Uj6Vh*Ujh*UmHnHujTh*Uh*jh*U6       FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT     FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       ºĺҺԺֺ"$&:<>BDFH\^`fhjlлһjpah*Uj`h*Uj_h*Uj9_h*Uju^h*Ujh*UmHnHuj]h*Uj@]h*Uj\h*Ujh*Uj6\h*Uh*3$&(<>@FHJL`bprt¼ļؼڼܼjeh*Ujdh*Uj;dh*Ujch*Uj:ch*Ujh*UmHnHujbh*Ujbh*Ujh*Uh*(&Jr¼`_^]\[/ =!"#$%essee's mail address (street address, PO Box, etc., where the mail will be delivered).2DCareOf UppercaseUEnter the Addressee's Supplemental Address (Example: Suite or Apartment Number, C/O)D CaseNumber Uppercase/Enter the Case Number (Example: V1234567A,B,C)D ClientCity UppercaseEnter the Addressee's City.D ClientState Uppercase1Enter the Addressee's 2 digit State Abbreviation.D 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 CoExtensiond`CJOJQJ_HmH sH tH VOV CoState1?d8(OJQJ_HkHmH sH tH bOb CoSuppaddress1@d8(OJQJ_HkHmH sH tH \O\ CountyName1Ad8(OJQJ_HkHmH sH tH ^"^ CountyNumberBd8(OJQJ_HkHmH sH tH VO2V CoZip1Cdt CJOJQJ_HkHmH sH tH NOBN Date11 Dd`CJOJQJ_HmH sH tH XRX District1Ed8(OJQJ_HkHmH sH tH LObL FaxAC Fd`CJOJQJ_HmH sH tH VOrV FirstName1 Gd`CJOJQJ_HmH sH tH XOX FirstName21 Hd`CJOJQJ_HmH sH tH `O` GranteeAddress1 Id`CJOJQJ_HmH sH tH \O\ GranteeCareof Jd`CJOJQJ_HmH sH tH XOX GranteeCity Kd`CJOJQJ_HmH sH tH `O` GranteeClientID Ld`CJOJQJ_HmH sH tH hh GranteeFirstName1Md8(OJQJ_HkHmH sH tH fOf GranteeLastName1Nd8(OJQJ_HkHmH sH tH ZOZ GranteeState Od`CJOJQJ_HmH sH tH ZOZ GranteeZip Pd` CJOJQJ_HkHmH sH tH XOX LastName1Qd8(OJQJ_HkHmH sH tH ZO"Z LastName21Rd8(OJQJ_HkHmH sH tH VO2V OtherID1Sd8(OJQJ_HkHmH sH tH VBV Section1Td8(OJQJ_HkHmH sH tH ^OR^ SuperAreaCode1 Ud`CJOJQJ_HmH sH tH dObd SuperExtension1Vd8(OJQJ_HkHmH sH tH dOrd SuperPhoneNumber1 Wd`CJOJQJ_HmH sH tH dOd SupervisorName1Xd8(OJQJ_HkHmH sH tH PP Unit1Yd8(OJQJ_HkHmH sH tH TT Worker1Zd8(OJQJ_HkHmH sH tH `O` WorkerAreaCode1 [d`CJOJQJ_HmH sH tH fOf WorkerExtension1\d8(OJQJ_HkHmH sH tH XOX WorkerFax ]d` CJOJQJ_HkHmH sH tH \O\ WorkerName1^d8(OJQJ_HkHmH sH tH ZOZ WorkerPhone1 _d`CJOJQJ_HmH sH tH ^O^ WorkerTitle1 `d` CJOJQJ_HkHmH sH tH ^^ countynumber ad` CJOJQJ_HkHmH sH tH TO"T District2 bd`CJOJQJ_HmH sH tH RO2R Section2 cd`CJOJQJ_HmH sH tH LOBL Unit2 dd`CJOJQJ_HmH sH tH TORT Worker2 ed` CJOJQJ_HkHmH sH tH ^b^ Countynumber fd` CJOJQJ_HkHmH sH tH `r` Countynumber1 gd` CJOJQJ_HkHmH sH tH \O\ Countynumber2 hd`CJOJQJ_HmH sH tH POP ***** id` CJOJQJ_HkHmH sH tH dOd GranteeFirstName2 jd`CJOJQJ_HmH sH tH @0 /*****Address1CareOf CaseNumber ClientCity ClientState ClientZip CoAddress CoAreaCodeCoCity CoExtension CoPhoneNumberCoState CoSuppaddressCounty CountyName CountynumberCoZip Date1DistrictFaxAC FirstName FirstName2GranteeAddress1 GranteeCareof GranteeCityGranteeClientIDGranteeFirstNameGranteeLastName GranteeState GranteeZip LastName LastName2 OtherIDSection SuperAreaCodeSuperExtensionSuperPhoneNumberSupervisorNameUnitWorkerWorkerAreaCodeWorkerExtension WorkerFax WorkerName WorkerPhone WorkerTitle***** CaseNumber1 ClientZip1 CoAddress1CoCity1 CoExtension1CoState1CoSuppaddress1 CountyName1CoZip1GranteeLastName1 GranteeZip LastName1 LastName21OtherID1SuperExtension1SupervisorName1Worker2WorkerExtension1 WorkerFax WorkerName1 WorkerTitle1 Captions 8pt(<Pdu!5FZn 1BVj~%9Mau lMVF~"(jr#'+.26;AMXYZ\_`8 \ >j*ldwPXb  -!y!Z""###{(ܗܘ& !"$%&()*,-/01345789:<=>?@BCDEFNOPQ[a  &(4:<HNP\bdpsu!-35ADFRXZflnz} )/1=@BNTVbhjv|~#%179EKMY_amsuFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF/GranteeFirstNameAddress1CareOf CaseNumber ClientCity ClientState ClientZip CoAddress CoAreaCodeCoCity CoExtension CoPhoneNumberCoState CoSuppaddressCounty CountyName CountynumberCoZipdate1DistrictFaxAC FirstName FirstName2GranteeAddress1 GranteeCareOf GranteeCityGranteeClientIDGranteeFirstNameGranteeLastName GranteeState GranteeZipLastName LastName2OtherIDSection SuperAreaCodeSuperExtensionSuperPhoneNumberSupervisorNameUnitWorkerWorkerAreaCodeWorkerExtension WorkerFax WorkerName WorkerPhone WorkerTitle)=Qev"6G[o 2CWk&:Nbv  !"#$%&'()*+,-.';Oct 4EYm~0AUi}$8L`t*@ $y(pppUnknownGz Times New Roman5Symbol3& z Arial?5 z Courier New5& zaTahoma"h0@?*  FMicrosoft Word Document MSWordDocWord.Document.89q