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Get NY LDSS-3134 2001-2021

R WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS. ■ CONSENT TO STERILIZATION ■ ■ STATEMENT OF PERSON OBTAINING CONSENT■ I have asked for and received information about sterilization from __________________________________. When I asked for the (doctor or clinic) information, I was told that the decision to be sterilized is completely up to me. I was told that I could decide not to be sterilized. If I decide not to be sterilized, my decision will .

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