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Declaration <br />Residential Facility Permitted by Mim�esota Statues 462357, Subd. 6a through 8 <br />Date: <br />Licensed Operator Name: <br />Office Address: <br />Phone: <br />Street City State Zip Code <br />Home Work Fax Emai1 <br />Location of Residential Facility: <br />Street Address <br />Legal Description of Property: <br />County Property Identification Number: <br />