Acceptable documentation that must be provided with the form includes:a copy of the statement showing the late charge/fee (please circle the charge for clarity),a copy of the statement from the bank or financial institution showing overdraft fees, ORother documentation such as utility bills, medical bills, payment receipts, etc., showing accrued late charges, ANDa completed W-9. Completed forms and documentation must be mailed to Commissioner Jeffrey Pack, Bureau for Social Services, 350 Capitol Street, Room 730, Charleston, WV 25301.
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