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Community Based Self Help Meeting Verification

* Indicates required field

Case Manager *

Name *

First

Last

Phase *

Sponsor's Name *

Date of Last Contact with Sponsor *

Are you monitored by GPS or electronic phone app? *

Are you Attending GED and/or and Approved Education Class? *

By submitting this document to DAC, I understand that it is a felony offense to knowingly and willfully make a false, fictitious, or fraudulent statement or representation or to make or use a false writing or document, knowing the document or writing to contain any false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any department or agency of the state or county government pursuant to O.C.G.A. 16-10-20.

Upload Copy of Verification Form with Discussion Leader Signatures (if applicable) *

Max file size: 20MB

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Community Based Self HelpOnline Submission

Community Based Self Help Meeting Verification

Community Based Self Help
Online Submission