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USDA SCRIP CARD SUCCESS
On-Line Reporting Form

Organization Information:

(*) USDA Affiliate Organization Name or USDA Region:

Personal Information:

Your Name:

(*) City:

(*) State:

Pharmacy Information: (*) Name of Pharmacy where you used your USDA Scrip Card:

(*) Pharmacy City:

(*) Pharmacy State:

(*) Describe your Successful use of the USDA Scrip Card and did you save any money: