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Get HI DHS 1139B 2013-2024

I/We, ____________________________________________________________, hereby certify and agree that all providers, representatives or agents of the individual/organization indicated here in this Attachment, for the provision of transportation services, or any other service under this agreement, is informed that payments are made from Federal and State funds. All individuals covered, or in any way associated with the organization indicated in this Part A who provide services and receive payment fo.

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