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Form 5305-SA for Brownsville Texas: What You Should Know
I am completing a business/trade operation consisting of my own home or office and an automobile. I will conduct that operations at least half or more of the time. 2. Furthermore, I understand and fully understand the following: Carrying a Class 4 medical insurance card will permit you to use this card for the treatment of injuries, sickness or loss of income, whether temporary or permanent, and not for the purchase of any insurance in connection with those circumstances. A valid credit card is required at the start of each period and at the end of each period to be used for the purposes of the program. a. Must be 21 years of age by the date I enter into this agreement. b. Must carry a valid credit card on the date you enter into this agreement and at the close of the program. The cost of the program will be 25.00. You are responsible for the cost of the program or any other additional costs you may incur when you enter into this agreement. The cost of the program for a group of participants may not exceed 50.00 for a calendar year. c. Cannot be purchased with cash. Any excess will remain your property and will be returned to you if you depart the program before the end of the calendar year. You may not sell or lease the excess without prior approval from Texas Commission on Environmental Quality. All receipts from this program will be deposited in the City's General Fund. d. Must submit a completed affidavit verifying his/her insurance policy to the District Director no earlier than the end of August and no later than November. e. Must report the injury to the DPS Office of the Medical Examiner with the required certification by the beginning of the week after he/she is healed. (This does NOT apply to persons in prison or who are unable to come to the office because they are in a treatment facility.) 3. Any money (including but not limited to tax refunds or federal refund or Social Security benefits) given to you as a reward for participating in this program and which is received within 60-days of the program's end will be remitted to the DPS Office of the Medical Examiner. TEXAS COMMISSION ON ENVIRONMENTAL QUALITY, TEXAS STATE GOVERNMENT Office of the Chief Medical Examiner, P.O. Box 340125, Austin, TX 78 a.
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