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Y, town or post office, state, and ZIP code a. Name and address on original return if different from above. (If same, write Same ) b. Date original return was filed: Form 40 Form 40A E40 Form 40NR c. Check Form originally filed: Yes No d. Has your Federal return been audited for the year being changed? Yes If Yes, attach copy of Federal report. If No, have you been advised that it will be? e. Check here if the change pertains to a net operat.

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