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Heck all that apply.) Name (not your trade name) a. Amended Trade name (if any) b. Successor employer c. No payments to employees in 2010 d. Final: Business closed or stopped paying wages Address Number 850110 OMB No. 1545-0028 Street Suite or room number City State ZIP code Read the separate instructions before you fill out this form. Please type or print within the boxes. Part 1: Tell us about your return. If any line does NOT apply, leave it blank. 1 If you were required to pay.

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