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RN Other: Penalty $ Interest $ (Please read the instructions before completing this form) (Send us the original keep a copy for your records) Date: Total $ PART I - GENERAL 3. Employer Identification Number (EIN) 4. Daytime telephone number 5. Form of payment (if any) 1. Business name and location (number, street, city, state, and zip code) 6. Type of return (Check all that apply) Check Quarterly Other (Specify) Annual EFT Money Order Address changed since last return was fil.

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