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ILLINOIS WORKERS' COMPENSATION COMMISSION PAGE 1 C A S E H E A R I N G S Y S T E M CARLSON, KURT 005 ARBITRATION CALL FOR CHICAGO 99005 ON 07×22/2015 SEQ CASE NBR PETITIONER NAME RESPONDENT NAME

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This is a tax form used for reporting income earned in the state of Illinois for the fourth week of July.

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