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Get Form W-10 (Rev. July 2011 ) - Internal Revenue Service

10 with your tax return. Instead, keep it for your records. Dependent Care Provider s Identification (See instructions.) Provider s taxpayer identification number Name of dependent care provider Please Address (number, street, and apt. no.) print or type City, state, and ZIP code If the above number is a social security number, check here . . . . . . Certification and Signature of Dependent Care Provider. Under penalties of perjury, I, as the dependent care provider, certify that my.

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