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Parent Signature Date PARENT SIGNATURE CONFIRMS PROOF OF TRANSFER AND WITHDRAWAL. Coalition Staff Date ELCAC Created Sept 2015 rev May 2016 rev Dec 2016 rev Jan 2017. Attach supporting documentation such as invoice receipt letterhead statement as proof of satisfactory of parent copayment collection or repayment agreement. 4424 NW 13th Street A-5 Gainesville FL 32609 Ph 352-375-4110 Fax 352-375-4131 notifications elcalachua.org Request to Withdraw or Transfer SECTION I To be completed by...
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