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I declare that the information on this certificate is correct and complete to the best of my knowledge and belief. Signature of Authorized Purchaser Print Name Here Title Date PR-78SSTA Rev. 10/09 45 48429 2 2 48 9 STATE AR IA IN KS KY MI MN NC ND NE NJ NV OH OK RI SD TN UT VT WA WV WY Identification Number If Required SSUTA Direct Mail provisions are not in effect for Tennessee.

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