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M N Serial Number AMENDED RETURN 1 TAXABLE YEAR: CALENDAR 2 FISCAL 3 Payment Stamp 52-53 WEEKS TAXABLE YEAR BEGINNING ON , AND ENDING ON , Employer Identification Number Taxpayer's Name Postal Address Department of State Registry No. Industrial Code Municipal Code Merchant's Registration Number Zip Code Location of Principal Industry or Business - Number, Street, City Telephone Number - Extension ( 1 First return 2 Last return Yes Yes CHANGE O.

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