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Get OR OR-PS 2017

Ubmit original form do not submit photocopy Taxpayer name(s) Letter ID Date from / Date to / / / Provider s name Provider s Social Security number (SSN) Provider s individual tax identification number (ITIN) Provider s federal employer identification number (FEIN) Complete this form for care you provided for the taxpayer(s) during the dates above. Dependent s name Dependent s age Total payment received for this dependent . Dependent s name.

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