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The method of collecting information complies with the Freedom of Information Act the Privacy Act of 1974 and OMB Circ* 108. This form should be used for medically related travel covered by the Federal Employees Compensation Act the Black Lung Benefits Act and the Energy Employees Occupational Illness Compensation Program Act of 2000. Expires 12/31/2016 2. Case/Claim Number 1. Claimant s Name Last First Mi. 3. Payee s Name if different from claimant s name last first mi. See instruction no. 3 o ...

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