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4. 5. 6. 7. 8. 9. 10. 11. State. Fuel. Type. Tax. Rate. Total. Miles. Taxable. Miles. Taxable ... I certify that the information on this form is correct and complete to the best of my knowledge. Signature.
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I certify that the is a statement affirming that the information provided is true and accurate to the best of one's knowledge.
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