| Total Months Received In State | [field-value] |
|---|---|
| Total Months Received Other States | [field-value] |
Months Received In State
| Number of Months | Start Date | End Date | Case Reference |
|---|---|---|---|
| [field-value] | [Date] | [Date] | [Case Reference No.] |
Months Received Other States
| Number of Months | Start Date | End Date | State |
|---|---|---|---|
| [field-value] | [Date] | [Date] | [field-value] |