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M. If the claim is incomplete, your reimbursement will be delayed. Original Claim Revision: (Check One) 1. 2. 3. 1. Agreement Number: 2. Name and Address of Institution: 3. Federal ID#: 4. Month and Year Claimed: 5. Total Number of Days Food Service was Provided for Month Claimed: Free 6a. Enrollment This Month: 6b. Proprietary Title XIX, Title XX or F/RP Centers Only: (Check One) XIX,XX F/RP FOR DSS USE ONLY Y Reduced M M D D Paid Total Center Enrollment Total Total Title XIX,.

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