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Fillable Printable Confidentiality Notice: The information contained in this facsimile may be confidential and legally privileged

Fillable Printable Confidentiality Notice: The information contained in this facsimile may be confidential and legally privileged

Confidentiality Notice: The information contained in this facsimile may be confidential and legally privileged

Confidentiality Notice: The information contained in this facsimile may be confidential and legally privileged

FAX COVER SHEET
Hardship Request
Date:
     
Sender:
     
To:
Bill Brautigam
Office Name:
     
Office Name:
APD Central Office
Address:
     
Address:
500 Summer St NE E12
City:
     
City:
Salem
State:
     
Zip:
     
State:
OR
Zip:
97301
Phone No.:
     
Phone No.:
503.947.5204
Fax No.:
     
Fax No.:
503.378.7823
Total Pages:
     
Re:
Application for hardship waiver
Potential APS case
     
ConfidentialityNotice:Theinformationcontainedinthisfacsimilemaybeconfidentialand
legallyprivileged.Itisintendedonlyforuseoftheindividualnamed.Ifyouarenotthe
intendedrecipient,youareherebynotifiedthatthedisclosure,copying,distribution,ortaking
ofanyactioninregardstothecontentsofthisfaxexceptitsdirectdeliverytotheintended
recipientisstrictlyprohibited.Ifyouhavereceived thisfaxinerror,pleasenotifythesender
immediatelyand destroythis coversheetalongwithits contents,anddeletefromyoursystem,
if applicable.
DHS 2009 (REV 9/2003)
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