In this example
[PDF File]Designation of Beneficiary
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example 4 on the Back of Part 1), you should only list Option A and Option B. Who can sign this form? The Insured or Assignee (if applicable) must sign this form. The signature of a guardian, conservator or other fiduciary (including, but not limited to, those acting according to a Power of Attorney or a Durable Power of Attorney) is not acceptable
[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))
[PDF File]Revised 8-2019 MVC Application for Oklahoma Certificate of ...
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Form 701-6 Page 2 Declaration of Damage or Theft The owner/legal agent of owner of a vehicle 10 years old or newer must complete the following Declaration, unless sur-
[PDF File]Disability Report- Adult
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Please explain why you stopped working (for example: laid off, early retirement, seasonal work ended, business closed) Even though you stopped working for other reasons, when do you believe your condition(s) became severe enough to keep you from working? (month/day/year) 4.D.
[PDF File]APPLICATION FOR CERTIFICATE OF TITLE AND REGISTRATION
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The information, including Social Security Number, is requested in accordance with Virginia Code §§46.2-623 and 46.2-629. Any person who refuses to supply the required information will be denied a certificate of title and/or registration.
[PDF File]PHQ-9* Questionnaire for Depression Scoring and ...
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PHQ-9* Questionnaire for Depression Scoring and Interpretation Guide For physician use only Scoring: Count the number (#) of boxes checked in a column. Multiply that number by the value indicated below, then add the subtotal to produce a total score. The possible range is 0-27. Use the table below to interpret the PHQ-9 score.
[PDF File]Edinburgh Postnatal Depression Scale (EPDS)
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Here is an example, already completed. I have felt happy: Yes, all the time Yes, most of the time This would mean: “I have felt happy most of the time” during the past week. No, not very often Please complete the other questions in the same way. No, not at all In the past 7 days: 1. I have been able to laugh and see the funny side of things *6.
[PDF File]Supplemental and Optional Contact Information for HUD ...
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OMB Control # 2502-0581 Exp. (02/28/2019) Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants SUPPLEMENT TO APPLICATION …
[PDF File]Hand Receipt/Annex Number
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* WHEN USED AS A: HAND RECEIPT/ANNEX NUMBER. For use of this form, see DA PAM 710-2-1. The proponent agency is ODCSLOG. FOR ANNEX/CR ONLY * c. SEC . d. UI
[PDF File]FL-150 INCOME AND EXPENSE DECLARATION
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Income (For average monthly, add up all the income you received in each category in the last 12 months and divide the total by 12.) FL-150 [Rev. January 1, 2019]
[PDF File]Vehicle/Vessel Bill of Sale
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X X X X Vehicle/Vessel Bill of Sale Use this form to gather necessary information when you sell your vehicle or vessel. Completing this form does not
[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
[PDF File]Certificate of Fact
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X Certificate of Fact Use this form to make a statement of fact. License plate/Registration number Vehicle Identification Number (VIN) or Hull Identification Number (HIN)
[PDF File]Request for Social Security Earnings Information
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earnings are not correct (for example, you have previously received earnings information from us and it does not agree with your records), we will supply you with more detail for the year(s) in question. Be sure to show the year(s) involved on the request form and explain why you need the information. If you do not tell us why you need the
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