DescriptionH Dependent exemption information see page 14 First name and middle initial 201001120094 Last name Relationship Social security number Date of birth mm-dd-yyyy If more than 9 dependents mark an X in the box. Page 2 of 4 IT-201 2012 Federal income and adjustments see page 14 Whole dollars only Wages salaries tips etc.. 1 Taxable interest income. 2 Ordinary dividends. 3 Taxable refunds credits or offsets of state...
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