Form 20 Form 5A - clean

The Health Center Program Application Forms

Form 5A - clean

Form 5A: Services Provided

OMB: 0915-0285

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0915-0285 can be found here:

2025-05-21 - No material or nonsubstantive change to a currently approved collection
2024-11-26 - No material or nonsubstantive change to a currently approved collection

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