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FORM P Community Services of Northeast Texas, Inc.
702 Revised 304 E.Houston ● P.O. Box 427
APR 10, 2018 Linden, Texas 75563
Disability Certification Form Approved for all programs
Applicant Name:
Applicant File Number:
I hereby certify that I am disabled as defined in one of the following:
• 7(9) of the Rehabilitation Act of 1973
• 1614 (a) (3) (A) or 223 (D) (1) of the Social Security Act
• 102 (7) of the Developmental Disabilities Services and Facilities Construction Act
(38 USC Chapter 11 or 15)
I receive benefits as a result of my disability.
I do not receive benefits as a result of my disability.
I do not receive benefits as a result of my disability, but I have applied for benefits.
Under penalty of perjury, I have provided truthful information in this
certification. In Texas, under Sec. 37.101 of the PENAL CODE, it is
a felony of the third degree to falsify this document.
Applicant's Signature Date
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