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Return this form to: Accounts Receivable Department PO Box 7770 London, KY 40742-9831 Fax Number: (866) 415-2232 AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT) Member(s) Name: Medicare
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Return this form to the designated tax authority.
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Individuals and businesses are required to file return this form to the tax authority.
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Fill out the form with accurate and complete information according to the instructions provided by the tax authority.
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The purpose of return this form to is to report income, expenses, and other relevant financial information to the tax authority for tax assessment purposes.
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