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Get Form W-10 (Rev. August 1996) (Fill-In Capable). Dependent Care Provider's Identification And

Nternal Revenue Service Part I Dependent Care Provider s Identification (See instructions.) Name of dependent care provider Please print or type Provider s taxpayer identification number Address (number, street, and apt. no.) If the above number is a social security number, check here City, state, and ZIP code Certification and Signature of Dependent Care Provider. Under penalties of perjury, I, as the dependent care provider, certify that my name, address, and taxpayer identif.

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