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Get WI Form 4500-113 2011-2024

Ce: Completion of this information is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months [s. 285.87, Wis. Stats.]. This form may be used to meet the notification requirements for the Department of Health Services, ch. DHS 159, Wis. Adm. Code. Personal information collected will be used for administrative purposes and ma.

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