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Get NYS DOH-4469 2009

APPLICANT’S ADDRESS BUSINESS NAME BUSINESS ADDRESS APPLICANT’S TELEPHONE NO. ( ) BUSINESS TELEPHONE NO. ( ) Note: Depreciation*, personal expenses and entertainment, personal transportation, purchase of capital equipment and payments of the principals on loans are NOT allowable deductions. Losses from previous years are also NOT deductible. (*Allowed for SSI-R applicants/recipients) MONTH ONE MONTH TWO MONTH THREE ________ /________ ________ / ________ I. BUSINESS INCOME ________ / ___.

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