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Print Cardholder s name last first middle initial. 3. Circle the correct letter to indicate if Cardholder is male or female. Cash register receipts are acceptable but Pharmacist Signature is required if any information is handwritten. Ask your pharmacist how you can purchase diabetic supplies with your prescription card REASON FOR CLAIM SUBMISSION OR SPECIAL NOTES ESI USE ONLY PLEASE READ THE FOLLOWING INSTRUCTIONS CAREFULLY AND COMPLETE FORM ON REVERSE SIDE. Cardholder s Information The...
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Div B8A-Five River is a form used for reporting certain financial information related to river activities.
Any individual or entity engaged in river activities as defined by the regulations is required to file div B8A-Five River.
Div B8A-Five River can be filled out electronically or manually following the instructions provided in the form.
The purpose of div B8A-Five River is to collect and report financial information relevant to river activities for regulatory and monitoring purposes.
Information such as revenue, expenses, investments, and other financial data related to river activities must be reported on div B8A-Five River.
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