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U.S. DOD Form dod-va-21-2545 OMB Approved No. 2900-0052 Respondent Burden 15 minutes 1A. FILE NO. REPORT OF MEDICAL EXAMINATION FOR DISABILITY EVALUATION 1B. 18. DATE SIGNED 19. SIGNATURE OF PERSON EXAMINED Do not print PENALTY - The law provides severe penalties which include fine or imprisonment or both for the willful submission of any statement or evidence of a material fact knowing it to be false or for the fraudulent acceptance of any payme.

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