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PO Box, or PMB no.) City State ZIP Code Total Number of Payees Included Part II Type of Income Check all that apply. A m Payment to Independent Contractor B m Trust Distributions C m Rents or Royalties D m Distributions to Domestic Nonresident Partners/Members/Beneficiaries/ S Corporation Shareholders E m Estate Distributions F m Elective Withholding G m Elective Withholding/Indian Tribe H m Other 1 Total Withholding, exclu.

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