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E? If Yes, give date the return was filed Yes No Under penalties of perjury, I declare that I have examined this return, including accompanying documents, and, to the best of my knowledge and belief, it is true, correct, and complete. Signature Title Date Employer's contact person Employer's telephone number Employer's fax number Employer's email address Form W-3c (Rev. 11-2015) For Official Use Only Transmittal of Corrected Wage and Tax Statements Departm.

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