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57 SAFETY PERFORMANCE HISTORY RECORDS REQUEST PART 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE I, (Print Name) First M.I. Last Social Security Number Hereby authorize: Date of Birth Previous Employer:

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What is cinforms ormsmedicexa - elliott-hartman?

It is a form used for reporting medical expenses.

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Individuals who have incurred medical expenses and need to report them for tax purposes.

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You need to provide details of your medical expenses, including the amount spent and the purpose of each expense.

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The purpose is to report medical expenses for tax deduction or reimbursement.

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You must report the date, amount, and purpose of each medical expense.