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Fill this form out by the 5th of the month for payment by the end of the month:
Upon submission it will be emailed to: firstname.lastname@example.org
Itasca County Health and Human Services: 1209 SE 2nd Avenue, Grand Rapids, MN 55744-3983
Please provide the date range of services being provided.
Place provide the date range of any temporary absences:
Reason for Placement:
This field is not part of the form submission.
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