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Name: Date: The following items are about activities you might do during a typical day. Does your HEALTH now limit you in these activities? If so, how much? Put a check in the appropriate box. ACTIVITIES

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Name date form following is a financial disclosure form that individuals must fill out to report their income, assets, and debts.

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On name date form following, individuals must report details such as income from employment, investments, real estate holdings, and debts.

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