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The parties agree to pay and receive the balance of the compensation at the rate of period of weeks beginning per week for a Signature of dependent next of kin or personal representative Signature of Employer Title Signature of Carrier/Administrator NORTH CAROLINA INDUSTRIAL COMMISSION THE FOREGOING AGREEMENT IS HEREBY APPROVED Signature of claimant s attorney CLAIMS EXAMINER DATE Attorney s address ATTORNEY S FEE APPROVED MAIL TO FORM 26D 2/01 P.

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