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Effective Date of the Transaction Add Change Close month day year Resource Identification Number (Use on change/close transactions only) SECTION 1 PROVIDER S NAME (Please Note: If you are reporting income with a Social Security Number, use your name here not the name of your business. If you are reporting income with an Employer Identification Number, use your business name here.) DOING BUSINESS AS (DBA) Complete this line only if you report income to the IRS under your Social Security.

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