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Get AK ADM-124 2014-2023

Tion Date of Appointment: Date of Screening Report: Services Provided (please use additional sheets if necessary): 1. 2. 3. 4. 5. Time (in tenths of hours) Amount Submitted for Payment $ I certify that my services in this case are completed and the facts stated above are true to the best of my knowledge and belief. Date Provider Signature FOR COURT USE ONLY Amount approved: $ Date ADM-124 (8/14)(cs) SCREENING INVESTIGATION BILLING FORM Lisa M. Fitzpatrick Administrative Attorney AS 47.

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