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Get PA DoR 83-A272 2016

Verse side of this form prior to completing this petition. Print or type all information. The completed petition must include: W-2 showing Federal, State, Medicare and Local wages Signature of Employee and Employer IRS Form 2106 if claiming expenses on Line 2E. If Form 2106 has an entry on Line 4, submit a breakdown of those expenses. EMPLOYEE'S NAME SOCIAL SECURITY NUMBER HOME ADDRESS CITY DAYTIME TELEPHONE NUMBER OCCUPATION STATE ZIP CODE IF PARTIAL YEAR, PROVIDE DATES: From EMPLOYER.

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