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Of at least $1,500.00? YES NO If YES in what month and year did (or will) this first occur? Month Year 16. Have you or do you expect to employ at least one worker in 20 different calendar weeks during a calendar year? YES NO If YES in what month and year did (or will) the 20th week occur? Month Year Signature: I hereby affirm that I am authorized to sign this report on behalf of the indicated employer, and further affirm that the information provided herein is complete and accurate.

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