amens or fraud irwohirg checks reflected onyore statement within 30 days after a was mailed a male available. • Please died customer complains et Polies to the Finn's< lent Relations Deparement X 201.352-1699 or tollfree at 800-354-9103, 8:00 A.M. lo 6 AO P.M. ET Monday through Frolay, or in vintir

able from the local county health department. FIRST MI DOB MO/DMYR Child's SS# (optional) SEA IF imMt UATION ID# VACCINE. DTaP/DTP2 DT3 Td' Polies HIB` MMR (Combined)' (Separate)' Hepatitis B' The state immunization ID# is an identifier supplied by the state immunization registry (optional)

from the local county healthelioa ion ructions on form co:aplenty ad im Ermaligif ‘annu ally and are available • a. VACCINE DTaP/DTP' DT' Td' Polies' MMR (Combined)' (Separate)' Hepatitis 219 t The state irrummization IDN is an identifier su .die statrommunizatiolficgistry (optional). 2 DTP