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Get NY TC 403 HA 2016

____________________________STA TE:____________Z IP:__________ If work was performed outside New York State, indicate state _______ EMPLOYER NAME:_______________________________QUARTERLY GROSS WAGES $___________ EMPLOYER ADDRESS: ________________________________________________________________ CITY:____________________________STA TE:____________Z IP:__________ Step 3 Acknow ledgement If work was performed outside New York State, indicate state _______ I certify that the above information is.

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