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Get In Wce-1 2006

E of Independent Contractor (type or print) Business Name Specified Trade Last, First Address (number, and street, city, state, ZIP code) E-mail Address Telephone Number (including area code) Social Security Number Are you an Indiana resident? ❑ Yes ❑ No Affidavit of Exemption Number (State Use Only) If no, please enter your state of residence: Under the provisions of IC 22-3-2-14.5 and/or IC 22-3-7-34.5, I, the undersigned, am hereby requesting issuance to me of an Independ.

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