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[PDF File]MEDICARE ENROLLMENT APPLICATION
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cms-855i see page 1 to determine if you are completing the correct application. see page 3 for information on where to mail this completed application. see section 12 for a list of supporting documentation to be submitted with this application. to view your current medicare enrollment record go to: https://pecos.cms.hhs.gov
[PDF File]Form I-693, Report of Medical Examination and Vaccination ...
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Form I-693 07/15/19. Page 1 of 14. Report of Medical Examination and Vaccination Record . Department of Homeland Security . U.S. Citizenship and Immigration Services
[PDF File]5304-SIMPLE Savings Incentive Match Plan Form for ...
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terminates a salary reduction election not in accordance with 2b may not resume salary reduction contributions during the calendar year. Article III—Contributions (complete the blank, if applicable—see instructions) 1 Salary Reduction Contributions.
[PDF File]Request for Social Security Earnings Information
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Form . SSA-7050-F4 (03-2019) Page 2 of 4. REQUEST FOR SOCIAL SECURITY EARNING INFORMATION . 1. Provide your name as it appears on your most recent Social Security card or the name of the individual whose
[PDF File]Patient Health Questionnaire (PHQ-9)
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PHQ-9 Patient Depression Questionnaire For initial diagnosis: 1. Patient completes PHQ-9 Quick Depression Assessment. 2. If there are at least 4 3s in the shaded section (including Questions #1 and #2), consider a depressive
[PDF File]APPLICATION FOR 10-POINT VETERAN PREFERENCE (TO BE …
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Page 1 of 2. APPLICATION FOR 10-POINT VETERAN PREFERENCE (TO BE USED BY VETERANS & RELATIVES OF VETERANS) U.S. Office of Personnel Management
[PDF File]Form W-9 (Rev. October 2018)
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than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: • An individual who is a U.S. citizen or U.S. resident alien; • A partnership, corporation, company, or association created or
[PDF File]Request for Leave or Approved Absence
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Request for Leave or Approved Absence. 1. Name (Last, first, middle) 2. Employee or Social Security Number (Enter only the last 4 digits of the Social Security Number (SSN))
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