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ANNEX "k. AFFIDAVIT-DECLARATION THAT NO PROFESSIONAL FEE HAS BEEN CHARGED BV MEDICAL PRACTITIONER we. 'Name Represe/'/atire) permanently residing at and permanently residing at Taxpayer Identification Number (TIN) hereby depose and state: - or legal ane, sine; or leaal age. J!21e/ married , after having been duly sworn in accordance With …
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