Ill. Admin. Code tit. 77, § 2800.APPENDIX A – Verification of Organ Transplantation Diagnosis and Legal Domicile

I hereby attest that to the best of my knowledge and as documented in the Patient's

medical records

was medically diagnosed as requiring an organ

(patient name)

transplantation on

that said Patient was a resident of the State of

(date of diagnosis)

Illinois on the date of diagnosis, living at a fixed address and with an intent to continuously reside in the State of Illinois; and that said Patient continues to reside in the State of Illinois at a fixed address and with the intent to remain a resident of the State of Illinois.

(Signature of Representative from Applicant Institution)

Subscribed and Sworn to before me

this

day of

, 19

(Signature of Notary Public)

My Commission expires

, 19

*Also include other pertinent documentation verifying patient's legal residence, i.e. driver's license or tax form.

PART 2800

2161/1451b/SP

(Added at 11 Ill. Reg. 9118, effective April 30, 1987)