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Forw A-3li
C~H2;02iVEALTH OF HAS S ACH U S STTS
bE PART?IENT OY PUBLI C S~E LFAtt E
ASSIGNNEN'C
t ~ ASSIGb'HENf,Op St!P?01T RIGH'fS
,
Ia co~~i~errtiaa of assistance Y~ceived pursuant to the provisions o~ ..' .
C'tinpier 2I3 of ttie ~~RS'3aC~llEtttS G neYa~l L,c+a (Aid to Fa~uili~a ~iiih Dcp~ttdet-t '
Cti;ildr~ ~~, I . ~ ` C/ , (.L%~ .~~ ~~'-i' ~ of ! I ~ ~C~_,~ _ , // '
±n cht cs -: Jto~m of ~1L~1 , Coc~ooavealih of Massachusetts~ ~
ib accoc~aace ~itb th~ provi~ions of the Unit~d Ststes Cade of Fzderal Regule-
tions~ i=tle 45~ Chnptrr 2. Prrt 232.11, and by the authority of Chapter 18~ -.
5cctions 10 nna 21 of Lht ~:a~aechusetts General Lava, do heYeby sssign. to th~ .-
T,~:pattc~at of ~ubl~c ~'elfare for ~h= Coc-...~nuenlth of Nassachuaetta any rights .
I me~ ~-a~ e to suppart fro~n ~ny other ptYaon. . ~ •'. ,
SucS Aasigtunt~t n.+y bt applicable for asaistance scceived by me or itt my -
~el~alf~ rs in bcl~blf o~ eny otl~rr family r.eraber. •_ ',
lr~dCitionally, tbis t_~stgnn+~nt ahall be appllcable to support vfiieb vsaY .
La~•e accrued pritrz tr- this data. '
~is Asai~t~at and agre'n:ent ahall aot apply again~t any •awunts due au
Hh~c3 •te i~ txCess flF e+.,ai:s ?aid Lo cx by the Departnec-t of Public ~elfare
purcu~+r~t to Cha~-ttt 118 af tlia :~i~saachu~etts CeneTal I.eu~.
~ undrttt~+~~ t,~at u, d~t Litla agst~rent any cwnies peid for auppoYt by
enrtb~r persoa ia cy ~ehelf o~ ~for ano:~-er far~ily tinr~nbeY teceiving assistantt
shail ba pat d dir~ctl1 L~ ttia DppaTtmenL iri accotdanze vith th~ provisions of -
Sectiaci 2 of Chapttr 116 of ihr Maas~-chssetcs Cstttrai 3.a~a~. If Lhe aoout~tt .
collee=ed is ia exctas of the amount due Lhe D~parta~ent, such exc=ss ahall ba
paia ~ tr.~ fB~~ir. .
Z cc'~c; ou2ed~e that I h~vE r=ad L:-ia agr~eoent oY t`iat it hsa beea teqd
to c~e n~3 I thor~~gh2y vndzYatand ita ^~ani~g bGfoze affixing ~y sigcature.
Vi~neas ~y e'gn~turg t?-ia ~~ ~/~ day flt 19~~
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Sigaature.
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1991 MAR -3 t,~ ~ 07
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:~~~x 349 ~~~Ei946
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