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_____________ Telephone #: ( ) ___ ___ ___ - ___ ___ ___ ___ Federal Tax ID #: ___ ___ ___-___ ___-___ ___ ___ ___ (Required) Section 4: Service Provision DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 FREQUENCY START TIME END TIME GROUP SIZE DATE FREQUENCY START TIME END TIME 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 GROUP SIZE Total # of Sessions: ____________ Rate: ___________Total Amount Due: _________________________ Section 5:Provider Certification for provision of Services P.

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