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Telephone Number (with area code) 2. APPOINTEE INFORMATION Name Provide one of the following identi cation numbers: State and State Bar Number Apartment/Suite No. Present Address - number and street, rural route City, Town or Post Of ce State State and Certi ed Public Accountant Number Zip Code Internal Revenue Service Enrolled Agent Number Daytime Telephone Number (with area code) Social Security or Other ID No. Type 3. TAX MATTERS: The appointee is authorized to receive co.

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