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Get UT DWS-UI 617B 2016-2021

) of Hearing: Appeal Case Number: Date Retained: Date Representation Ended: Total Amount of Expenses/Fees PAID by Claimant to date: Total Fee (including any pre-paid amount) Requested: DATE $ $ ITEMIZED SERVICE (i.e. research, preparation of appeal, attendance at hearing) ACTUAL TIME REQUIRED I certify that the above information and the information provided in response to the questions on the second and third pages of this form is true and correct to the best of my knowledge. Printed .

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