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Ber First name and Middle Initial REFUND Last Name Spouse's Social Security Number If a joint return, spouse's first name and initial AMENDED Last Name Filing Status: Attach all forms and applicable Federal schedules and/or documentation to the back of this return. Employer(s) and address where work performed Trade Name City of Employment #1 City of Employment #2 LESS FEDERAL FORM 2106 (if applicable - you must attach a copy) (-) NET WAGES (enter in Column B below) ( ) TAX CALCULAT.

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