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This form must be filled out completely before any treatment is rendered. Owners Name: Coowner×Spouse: First Last Address: Street City State Zip Cell Phone: Cell Phone: Home Phone: Place of Employment:
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This form is a tax form.
Individuals or entities earning income.
The form must be filled out completely and accurately.
The purpose of this form is to report income to the tax authorities.
Income, deductions, and credits must be reported on this form.
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