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Get 1545-0717 Department Of The Treasury Internal Revenue Service 2000 Your Social Security Number Type

R sick pay. Your social security number Type or print your full name Home address (number and street or rural route) City or town, state, and ZIP code Claim or identification number (if any) I request income tax withholding from my sick pay payments. I want the following amount to be withheld from each payment. (See Worksheet below.) Employee s signature Date $ Cut here and give the top part of this form to the payer. Keep the lower part for your records. Worksheet (Keep fo.

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