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L Information 2.Reporting Period 4. Verification of Tax Report Name: Month or Qtr/Year: I declare that the information in this report is correct. Signature Title Date Street: 3. License No: City, State, Zip: Business Phone: ( ) th INSTRUCTIONS This report MUST be filed on or before the 15 day of the month following the reporting period whether or not any transactions have th occurred. Reports or payments postmarked after the.

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