Thank you for agreeing to share your story. Through your participation, decision makers will know how policy choices translate to impact in our state. Please note that the short story you share about the impact of the budget cuts may be posted on our website for public viewing. If you desire, you may indicate that you would like your story to be posted without your identifying information. Your advocacy is essential to ensuring everyone in Connecticut has an opportunity to thrive. Thanks again!

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* 1. Full name

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* 2. Street address

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* 3. City

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* 4. State

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* 5. ZIP code

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* 6. Phone number

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* 7. Email address

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* 8. Are you willing to speak to the press? 

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* 9. May we identify your story by name and/or town on our website?

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* 10. Have you or someone you are a caretaker for received a letter from the Department of Social Services related to the possible termination of your Medicare Savings Program benefits?

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* 11. What is your relationship to the impacted individual?

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* 12. How will losing your benefits through the Medicare Savings Program impact you or the person for whom you provide care? What will this mean for your finances, health, or well-being?

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