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Get Fl Dr-416 2008

Chapter 458 or Chapter 459, Florida Statutes, hereby certify Mr., Mrs., Miss, Ms., (Circle one) Patient s Name (Please Print) Social Security Number , is totally and permanently disabled as of (Social Security Number required under s. 196.101, Florida Statutes.) January 1, , due to the following mental or physical condition(s): Quadriplegia Other total and permanent.

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