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To Rico Internal Revenue Code of 1994, as amended Payment Stamp Name Address Account Number Payment Date Tax Year Amount Paid 0 0 Y Y M M D D CUT ALONG THE DOTTED LINE BEFORE FILING THIS FORM. CODE 0143 CUT ALONG THE DOTTED LINE BEFORE FILING THIS FORM. CUT ALONG THE DOTTED LINE BEFORE FILING THIS FORM. CUT ALONG THE DOTTED LINE BEFORE FILING THIS FORM. INSTRUCTIONS This form is to be used exclusively for the payment of estimated tax regarding the net income attributable to Puerto.

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