Professional legal forms

Dci tatda claim forms DENTAL COUNCIL OF INDIA NEW DELHI GUIDE LINES FOR PREPARATION OF TA/DA CLAIMS ON TEM. DUTY MOVES Contents Contents respecting TA/DA bill form alongwith guidelines and other required information for

Ej 160 claim of exemption on l... This includes providing spaces for an email address and a fax number. In addition a new item 1 has been added to the Claim of Exemption Wage Garnishment form WG-006 in which to enter the name of the person making the claim. The subsequent items on the form have been renumbered accordingly. This item already exists on Claim of Exemption Enforcement of Judgment form EJ-160 but it has been slightly revised so that the text the item will be identical...

Ups scs customer cargo claim f... UPS-SCS Customer Cargo Claim Form Press F1 on any field for help Claim Amount (specify currency): Is hereby filed for (check one): Date filed: UPS Bill of Lading/Air Waybill No: UPS Bill of Lading/Air

Colorado quit claim deed joint... Prepared By and After Recording Return to: Send Tax Statements to Grantee (Name and Address): --------Above This Line Reserved For Official Use Only-------- QUITCLAIM DEED Individual to Two Individuals

Georgia claim of lien sect44 1... After Recording Return to: CLAIM OF LIEN STATE OF GEORGIA, COUNTY OF LIEN CLAIMANT: , a (mechanic, contractor, subcontractor, materialman, machinist, manufacturer, registered architect, registered

Quit claim deed form individua... This document prepared by (and after recording return to): Name: Firm/Company: Address: Address 2: City, State, Zip: Phone: ) ) ) ) ) ) ) ) ) ) --------Above This Line Reserved For Official Use Only-------------

Quit claim deed georgia form This document prepared by (and after recording return to): Name: Firm/Company: Address: Address 2: City, State, Zip: Phone: ) ) ) ) ) ) ) ) ) ) --------Above This Line Reserved For Official Use Only-------------

Claim form nj NJ DIRECT Claim Form NJ State Health Benefits Program SHBP Please Print This Form In Color If Available. Please write your NJ DIRECT identification number clearly on the first page. CLAIM FORM MAY BE ADDITIONAL INFORMATION IS NOT SUPPLIED HELPFUL HINTS When you are submitting expenses for more than one family member please use a separate claim form for each person. It is suggested that you make copies for your own use before you submit the original bills. WHERE TO SUBMIT YOUR CLAIM FORMS Please mail completed claim form for MEDICAL CLAIMS TO Horizon Blue Cross Blue Shield of New Jersey P. O. Box 820 Newark NJ 07101-0820 MENTAL HEALTH/SUBSTANCE ABUSE CLAIMS TO Magellan/NJ DIRECT PO Box 5172 Columbia MD 21045-5172 FRAUD WARNING ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES TO REPORT SUSPECTED FRAUD CALL 1-800-624-2048 AT HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY. LAST NAME OF SUBSCRIBER 22. SEX 26. HEALTH COVERAGE PLAN NAME OR PROGRAM NAME AUTHORIZATION 27. I certify that the information provided is correct and complete and that I am claiming benefits only for charges actually incurred by the patient named. I authorize any provider who participated in care and treatment to release to Horizon Blue Cross Blue Shield of New Jersey Horizon BCBSNJ all medical or other information requested for the processing of this claim. I agree that New Jersey State auditors NJ State Health Benefits Program and Horizon BCBSNJ may see or get a copy of any such medical records. This information is for the sole use of the New Jersey State Health Benefits Program and Horizon BCBSNJ to administer and analyze the health program. Unless a law requires it information will not be given in an identifiable form to any other persons unless I agree to its release in writing. If you have any questions about how to submit your Claims please call the Customer Service 1-800-414-SHBP 7427. WHERE TO SUBMIT YOUR CLAIM FORMS Please mail completed claim form for MEDICAL CLAIMS TO Horizon Blue Cross Blue Shield of New Jersey P. This information is for the sole use of the New Jersey State Health Benefits Program and Horizon BCBSNJ to administer and analyze the health program. Unless a law requires it information will not be given in an identifiable form to any other persons unless I agree to its release in writing. I agree to reimburse Horizon BCBSNJ should this claim be incorrectly paid. 28. SIGNATURE OF PATIENT unless a minor Spouse Civil Union or Domestic Partner 2642 W0208 DATE SEE BACK OF THIS FORM FOR IMPORTANT INFORMATION An Independent Licensee of the Blue Cross and Blue Shield Association PLEASE READ THIS IMPORTANT INFORMATION WHEN YOU ARE SUBMITTING EXPENSES FOR MORE THAN ONE FAMILY MEMBER PLEASE USE A SEPARATE CLAIM FORM FOR EACH PERSON. ITEMIZED BILLS FOR COVERED SERVICES OR SUPPLIES MUST BE ATTACHED TO THIS FORM AND INCLUDE THE FOLLOWING Check that each itemized bill is legible and contains ALL of the following information NAME ADDRESS of person or institution rendering the service or supplying the item PATIENT S FULL NAME BILLS MISSING ANY OF TYPE of service rendered/produced or item supplied THIS INFORMATION MAY DATE each service rendered or item supplied BE RETURNED TO YOU AMOUNT charged for each service rendered or item supplied DIAGNOSIS of ailment Cash register receipts cancelled checks money order receipts personal itemizations and bills only noting a balance due are not acceptable. I agree to reimburse Horizon BCBSNJ should this claim be incorrectly paid. 28. SIGNATURE OF PATIENT unless a minor Spouse Civil Union or Domestic Partner 2642 W0208 DATE SEE BACK OF THIS FORM FOR IMPORTANT INFORMATION An Independent Licensee of the Blue Cross and Blue Shield Association PLEASE READ THIS IMPORTANT INFORMATION WHEN YOU ARE SUBMITTING EXPENSES FOR MORE THAN ONE FAMILY MEMBER PLEASE USE A SEPARATE CLAIM FORM FOR EACH PERSON. ITEMIZED BILLS FOR COVERED SERVICES OR SUPPLIES MUST BE ATTACHED TO THIS FORM AND INCLUDE THE FOLLOWING Check that each itemized bill is legible and contains ALL of the following information NAME ADDRESS of person or institution rendering the service or supplying the item PATIENT S FULL NAME BILLS MISSING ANY OF TYPE of service rendered/produced or item supplied THIS INFORMATION MAY DATE each service rendered or item supplied BE RETURNED TO YOU AMOUNT charged for each service rendered or item supplied DIAGNOSIS of ailment Cash register receipts cancelled checks money order receipts personal itemizations and bills only noting a balance due are not acceptable. COORDINATION OF BENEFITS If you or your covered dependent s are covered by another health insurance program please provide the information requested in the Other Health Coverage Section. Example Spouse covered by another insurance company or other Horizon Blue Cross Blue Shield of New Jersey coverage.

Aflac specified health event c... SPECIFIED HEALTH EVENT CLAIM FORM Accident Policy Number Hospital Indemnity/Specified Health Event Be sure to include your policy number s on all documents. Failure to complete this form in its entirety may result in a delay in processing this claim. INSTRUCTIONS Complete Section A Policyholder/Patient Information and sign your claim form. Have the treating physician complete Section B Physician s Statement and sign the claim form. If you are fil...

Carefirst blue cross blue shie... INSTRUCTIONS TO SUBMIT A MAJOR MEDICAL CLAIM When you have enough charges to satisfy your deductible, you may file a Major Medical claim! You DO NOT have to wait until the end of the year. In fact,

Washington quitclaim form QUITCLAIM DEED SAMPLE THIS SPACE PROVIDED FOR RECORDER S USE FILED FOR RECORD AT REQUEST OF John Smith WHEN RECORDED RETURN TO NAME John Smith ADDRESS P. O. Box 320 CITY STATE ZIP Seattle WA 98101 THE GRANTOR S John Smith for and in consideration of One dollar and love and affection conveys and Quitclaims to the GRANTEE S John Smith Jr. and Mary Smith husband and wife the following described real estate situated in the County of King State of Washington together with all after acquired title of the Grantor s therein legal description The Southerly 90 feet of lots 8 and 9 Block 12 Stewart s first addition to Highland home an addition to the City of Seattle as per plat recorded in Volume 2 of plats page 85 Records of King County situated in the County of King State of Washington. Tax Parcel Number 3355479823 DATED Grantor State of Washington County of ss On this day personally appeared before me and Grantor s to me known to be the individual s described in and who executed the foregoing instrument and acknowledged that s/he signed the same as his/her free and voluntary act and deed for the uses and purposes therein mentioned. GIVEN under my hand and official seal this day of NOTARY PUBLIC in and for the State of Washington Residing at My commission expires NAME ADDRESS CITY STATE ZIP the following described real estate situated in the County of after acquired title of the Grantor s therein legal description described in and who executed the foregoing instrument and acknowledged that s/he signed the same as his/her free and voluntary act and deed for the uses and purposes therein mentioned. Residing at. Quitclaim Deeds and Life Estates What is a Quitclaim Deed What if I want my property back after I sign the form All real estate transactions must be in writing. If you change your mind later and decide you want to keep the property it may be impossible or very hard to undo the deed unless the Grantee agrees to Quitclaim the property back to you. A quitclaim deed is one way to transfer real property such as A house or Land or Certain mobile homes. If the Grantee refuses to Quitclaim the prove that the transfer was invalid* Examples You signed the deed under threats or other extreme pressure or you signed it due to lies the Grantee told you. You may have to hire a lawyer to invalidate the transfer. That can be very expensive. It may not work. The person who transfers the property by selling it or making a gift of it is called the Grantor. The person the property is transferred to is the Grantee. types of deeds. The Grantor of a Quitclaim deed makes no guarantee or promises that the property is free of debt. Also with a Quitclaim deed the Grantor makes no promises that no one else claims to own Do not sign the quitclaim deed if you feel threatened or RUSHED OR under pressure to sign it. Do not sign the deed if you feel the person you are giving the property to may be lying about something related to the property or your ability to continue living there.

Kansas form d 22a KANSAS DEPARTMENT OF REVENUE DIVISION OF VEHICLES DEALER LICENSING BUREAU DOCKING STATE OFFICE BUILDING TOPEKA, KANSAS 66626-0001 Phone: (785) 296-3621 Fax (785) 296-5854 Web Site: www.ksrevenue.org/dmv

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