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[PDF File]TINETTI BALANCE ASSESSMENT TOOL
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TINETTI BALANCE ASSESSMENT TOOL GAIT SECTION Patient stands with therapist, walks across room (+/- aids), first at usual pace, then at rapid pace. Risk Indicators: Tinetti Tool Score Risk of Falls ≤18 High 19-23 Moderate ≥24 Low Date Indication of gait (Immediately after told to ‘go’.) Any hesitancy or multiple attempts = 0 No hesitancy = 1
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[PDF File]2018 Instructions for Form 709
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gifts, your spouse must sign line 18 in Part 1—General Information. Who Must File. In general. If you are a citizen or resident of the United States, you must file a gift tax return (whether or not any tax is ultimately due) in the following situations. • If you gave gifts to someone in 2018 totaling more than $15,000 (other than to
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[PDF File]STATE OF TENNESSEE DEPARTMENT OF LABOR AND …
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DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF EMPLOYMENT SECURITY (mm/dd/yy) (mm/dd/yy) INSTRUCTIONS SEPARATION NOTICES Rule 0800-09-01-.02 of the Rules and Regulations of the Tennessee Employment Security Law, requires all employers
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[PDF File]Form W-9 (Rev. October 2018)
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other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. Sign Here. Signature of U.S. person Date . General Instructions. Section references are to the Internal Revenue Code …
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[PDF File]Request for Social Security Earnings Information
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4. I am the individual to whom the record pertains (or a person authorized to sign on behalf of that individual). I understand that any false representation to knowingly and willfully obtain information from Social Security records is punishable by a fine of not more than $5,000 or one year in prison.
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[PDF File]2766 Property Transfer Affidavit
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Michigan Department of Treasury 2766 (Rev. 05-16) L-4260 Property Transfer Affidavit This form is issued under authority of P.A. 415 of 1994. Filing is mandatory. This form must be filed whenever real estate or some types of personal property are transferred (even if you are not recording a deed).
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[PDF File]Form 1957 - Bill of Sale or Even-Trade Bill of Sale
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The seller must complete all applicable information and sign this form. The Bill of Sale or Even-Trade Bill of Sale must be notarized when showing proof of ownership on major component parts of a rebuilt vehicle or when specifically requested to be notarized by the
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[PDF File]FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR …
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8 motor vehicle identification number verification this section requires a physical inspection and a verification of the vehicle identification number (vin) (or the motor number for motor vehicles manufactured prior to 1955) of the motor vehicle described on this form by a licensed dealer, florida notary public, police officer, or florida division of motor vehicles
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[PDF File]CMS 1763 Request for Termination of premium Hospital an/or ...
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REQUEST FOR TERMINATION OF PREMIUM HOSPITAL AND/OR SUPPLEMENTARY MEDICAL INSURANCE . The completion of this form is needed to document your voluntary request for termination of Medicare coverage as permitted under the Code of Federal Regulations. Section 1838(b) and
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[PDF File]MEDICAL REQUEST FOR HOME CARE HCSP- M11Q …
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EIGHT HELPFUL HINTS FOR ACCURATE COMPLETION OF THE MEDICAL REQUEST FOR HOME CARE (M11Q) HCSP-712b 12/09/2014 * Please provide this sheet to the physician filling out the Medical Request for Home Care (M-11Q). ... The physician must sign and date the M -11Q within 30 days after the exam date. 7. The registry number, NPI (national provider ID ...
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