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See form DHS 1005 Client Information Seniors and People with Disabilities SDS 539A Contact date/Date of request Last name First name MI Address City State Zip code Telephone Mailing address if different Date of birth Social Security Marital status single married divorced widowed separated Citizenship U*S* citizen non-citizen Gender M F Disabled yes no Blind yes no Do you intend to stay in Oregon I live in house room board adult foster home apartment nursing facility other specify Veteran spouse ...

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