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Get and Sign Form W 10 Rev August 2009
State, and ZIP code
Certification and Signature of Dependent Care Provider. Under penalties of perjury, I, as the dependent care provider, certify that my
name, address, and taxpayer identification number shown above are correct.
Please
Sign
Here
Part II
Dependent care provider’s signature
Date
Name and Address of Person Requesting Part I Information (See instructions.)
Name, street address, apt. no., city, state, and ZIP code of person requesting information
General...
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