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Government Action on Claims Due the United States) (NOTE: Use additional sheets where space on this form is insufficient or continue on reverse side of pages.) Authority for the solicitation of the requested information is one or more of the following: 42 CFR 405.376; 4 CFR 101, et.seq.; 31 U.S.C. 951, et seq. The principal purpose for gathering this information is to evaluate your capacity to pay the Government s claim against you. Disclosure of the information is voluntary. If the requeste.

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