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Get Or Or-ps 2016

Ayer name(s): Letter ID: Date from: Date to: Provider s name: Provider s SSN or FEIN: Complete this form for care you provided for the taxpayer(s) during the dates above. Dependent s first name Dependent s last name Total payment received for this dependent $ $ $ $ $ $ Total payments you received from the taxpayer(s) $ $ $ $ Total $ $ $ $ $ Dependent s age.

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