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| Received Date |
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|---|
Third Party Liability Enforcement Evidence Details
Enter the household member whose third party payments are being assigned to the state.
| Household Member |
|---|
If an assignee is acting on behalf of the household member selected above, enter the assignee here.
| Assignee | |||
|---|---|---|---|
| Assign Third Party Payment Rights | Cooperate With TPL Requirements | ||
| Non Compliance Reason |