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If you would like to apply for assistance, please complete and "Send" this form to HDRC.
Last Name:
First Name:
Street Address:
City:
State:
Zip Code:
Phone:
Email Address:
Age:
Birthdate:
(MM/DD/YYYY)
Disability:
Briefly Describe Your Problem:

Who is representing you or assisting you with your problem?

If you are having difficulty using this form:

You may request this form over the telephone. Please call:
  • 1-800-882-1057

Or send us the information requested above by email:

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