Georgia Department of Human Services
Total Due:$_____ Minus Total Paid:$_____ = Balance Due: $_____ as of _____. I certify that all of the information supplied by me is true and correct to the best of my knowledge and belief. I understand the criminal penalties for making false statements and false swearing under O.C.G.A. ยง16-10-71 and do hereby attest to the truthfulness of the ... ................
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