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Name of Healthcare Facility ReceivingRequesting Funding Street Address City State Zip Code Date Signature of Authorized Official Please mail form to U
Name of Healthcare Facility ReceivingRequesting Funding Street Address City State Zip Code Date Signature of Authorized Official Please mail form to U

Name of Healthcare Facility ReceivingRequesting Funding Street Address City State Zip Code Date Signature of Authorized Official Please mail form to U - PDF document

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Name of Healthcare Facility ReceivingRequesting Funding Street Address City State Zip Code Date Signature of Authorized Official Please mail form to U - Description

S Department of Health Human Services Office for Civil Rights 200 Independence Ave SW Washington DC 20201 Name and Title of Authorized Official please print or type ASSURANCE OF COMPLIANCE ASSURANCE OF COMPLIANCE WITH TITLE VI OF THE CIVIL RIGHTS AC ID: 36738 Download Pdf

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