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Get Form 05 158 A

T 05/15/2014 01/01/2014 Taxpayer name 12/31/2014 Secretary of State file number or Comptroller file number Mailing address City State Country Blacken circle if this is a combined report Blacken circle if Total Revenue is adjusted for Tiered Partnership Election, see instructions Blacken circle if this is a Corporation or Limited Liability Company ZIP Code m d d y Blacken circle if the address has changed Blacken circle if this is an Entity other than a Corporation or Limited Li.

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