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Get IN Form 28808 2017-2024

listed on such bill. The dates, days, hours and units of time and costs for placement or service are true and accurate. I understand that in submitting this that I am under oath stating and affirming that these services were provided and fully understand that these services may be independently audited and that any discrepancy may be referred to a local prosecutor for criminal prosecution. 22. Signature of vendor 23. Telephone number of vendor 24. E-mail address of vendor 25. Date (month, da.

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