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Get US Court Official Form 122C-2

First Name Middle Name Case number (if known) Last Name People who are under 65 years of age 7a. Out-of-pocket health care allowance per person $ 7b. Number of people who are under 65 X 7c. Subtotal. Multiply line 7a by line 7b. $ Copy here $ Copy here + $ People who are 65 years of age or older 7d. Out-of-pocket health care allowance per person $.

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