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MADISON COUNTY EMS PATIENT NAME: DATE: ADDRESS: D.O.B: This form is being provided to me because I have: (check all that apply) REFUSED ASSESSMENT REFUSED TREATMENT REFUSED TRANSPORT I understand
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This form is being a tax form used for reporting income and expenses.
Individuals or businesses who have income or expenses to report.
The form can be filled out manually or electronically, following the provided instructions.
The purpose of this form is to report financial information to the tax authorities.
Income, expenses, deductions, and other financial details.
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