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O LIEAP <br />Q CIP <br />Name: <br />Address: <br />Telephone: <br />Email: <br />Please indicate which program: <br />❑ LIEAP <br />❑ CIP <br />This plan must be approved by the local Board of Social Services/Human Services Board <br />or local agency governing body prior to submission. Refer to the latest Dear County <br />Director Letter for instructions on how to submit this document to the North Carolina <br />State office. <br />Board of Social Services/Human Services or governing body Signature <br />Date <br />I �44W & Uha"w <br />Directors Signature <br />I 1231 as�g <br />Date <br />AWachmenl number 1 \n <br />F-11 Page 113 <br />