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Ttached Forms 4669, Statement of Payments Received, listed below. Number of Statements Year Total statements attached Signatures I certify that either (1) the statements were signed in my presence, or (2) to the best of my knowledge and belief the signatures on the statements are valid and legal. Date Date Title Date By Catalog No. 23290O www.irs.gov Form 4670 (Rev. 1-2004) Instructions for Payor Section 3402(d) of the Internal Revenue Code provides that you can be relieved of payment.

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