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Ifying No.) If resubmission, list Original ATI No. Employer: (Additional response for agencies specified by statute) Employer Name Street No. City Street or PO Box State Live Scan Transaction Completed By: Transmitting Agency BCII 8016 (Rev04/01) Mail Code (five digit code assigned by DOJ) Zip Code Name of Operator ATI No. ( ) Agency Telephone No. (Optional) Date: Amount Collected/Billed ORIGINAL-Live Scan Operator; SECOND C.

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