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Get Indiana Workers Comp Waiver Form 2015-2024

Valid for one year from the date of issue. You must re-apply each year to maintain exempt status. This information may be shared with the Internal Revenue Service and/or other states. FOR STATE USE ONLY A $20.00 non-refundable filing fee is required. $5.00 Department of Revenue filing fee paid Date issued (month, day, year) $15.00 Worker's Compensation Board filing fee paid APPLICATION CHECKLIST Part of State Form 45899 This Application for Certification of Exemption represents a statement.

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