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OMB No. 09381378 Expires: 7/31/2025EXHIBIT 1: MODEL INDIVIDUAL ENROLLMENT REQUEST FORM TO ENROLL IN A MEDICARE ADVANTAGE PLAN (PART C) OR MEDICARE PRESCRIPTION DRUG PLAN (PART D) Who can use this

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Expires 7312025 refers to a specific tax form or document that is due for filing or completion by the date July 31, 2025.

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