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MEDICAID PROVIDER AGREEMENT NUMBER: PROGRAM TYPE & CODE NUMBER: AGENCY CODE: A. HUD SECTION 8/811 SUBSIDY:* (From Commitment Form HUD 92264) AMOUNT $ B. REVENUE: 1. HUD Section 8/811 Revenues 2. Other (Attach detail for revenue items $1,000) 3. Other (Attach detail for revenue items $1,000) 4. Other (Attach detail for revenue items $1,000) 5. Other (Attach detail for revenue items $1,000.

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