Discharge Counselor - Data Form
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2024 Data Submission Form
Please use this form to submit a monthly count on the number of personal documents you help a consumer obtain and identify the payment source used.
Personal documents include State-issued Identification Cards, Driver's Licenses, Social Security Card, and Birth Certificate.
If you have any questions about how to complete this form please reach out to Erika C
Email: ecoronado@varpinc.org
Desk #: 909-506-1240