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4�{d3II <br /> 'VIatANT\A51E: TLe- l� <br /> ' dATE C0,1PLIANCE(I)OCUMENTATION': <br />{ v <br /> 1 h✓ J T e V <br /> I <br /> �CG�iV <br /> c <br /> Q- - - t C V - <br /> r L0- <br /> .lel )E .. C G'�'� l -SSC <br /> —I <br /> IQJ <br /> � <br /> _ I <br /> •�'� " i 'b� C L.' ._I � I rtJ � G l <br /> Continued on reverse <br /> ONFIRAUT.ION OF CORRECTIVE ACTION COMPLIANCE <br /> Claimant in corrccticc action compliance <br /> Claimant not in corrccticc action compliance (90 d1ly letter required) <br /> 4Claimant n ' 1 corr • .e action coil, lice- rejection recommended <br /> LEADAGENCY A DATE <br /> CLAIMS REVI _. R SIGNATURE DATE <br /> Page 3 <br />`` USTCF025.CO\t(\ew 11/97) . <br />