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 If you are applying or completing a review for SNAP, TANF, Medicaid, Child Care Assistance or LIHEAP and are having technical issues, complete this form. Please only attach screen shots of error messages. No case documentation should be submitted with this form.

 If you have questions about your benefits, filling out an application/review, or submitting supporting documentation, please contact the Customer Support Center:

 You may also visit your local human service zone office (formerly called county social service office) for in-person assistance.

 Please select the checkbox if you wish to enter additional sensitive information.
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