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9 If you filed a physician s statement for this disability in an earlier year, check this box. You do not have to file another statement. If you have not, you must file a physician s statement (see instructions). Physician s Statement of Permanent and Total Disability Please complete and return to the person named below. Name of disabled person I certify that the person named above was (check only one box please see instructions below) (1) Permanently and totally disabled on Jan.

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