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Form Application for United States Residency Certification Rev. April 2012 Department of the Treasury Internal Revenue Service OMB No. 1545-1817 See separate instructions. Important. For applications filed after March 31 2012 the user fee is 85 per application. Additional request see instructions Electronic payment confirmation no. For IRS use only Pmt Amt Foreign claim form attached. Deposit Date / Date Pmt Vrfd Applicant s name Applicant s U.S.

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