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Get and Sign Privately Owned Vehicle POV Mileage Reimbursement Rates 2020-2022 Form
Utilities Combined Monthly Average Groceries Insurance Car Payment Entertainment Telephone Include Cell Phone Tuition/Education Include Student Loans Other Loan Payments List Type Credit Card Payments Total per month Doctor/Hospital Copays Deductibles Monthly out of pocket cost only Medicare Premiums Part B Supplemental Other Medical Expenses List Type Other Expenses List Type Total monthly expenses from all sources listed above Coverage Information Are you on Medicaid Yes No Are you covered...
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