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Return completed form to J.J. Stanis Company Inc. J.J. Request for Dependent Care Reimbursement J.J. STANIS COMPANY INC 100 Jericho Quadrangle Suite 101 Jericho NY 11753 Fax Number 1-516 465 3920 Employer Group Number Employee Name SS No. Last First Middle Home Address Number/Street City Please check only if this is a new address.
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