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Name of Certified Investor Taxpayer Number Address City State ZIP Code Name of Contact Person Phone Number Area code and number FAX number Area code and number Email address AMOUNT OF ORIGINAL INVESTMENT CAPCO THAT RECEIVED INVESTMENT TOTAL CREDITS TO BE TRANSFERRED Whole dollars only Insurer Receiving Credit Transfer Transferee Contact Name AMOUNT OF CREDIT TRANSFERRED Taxpayer NAIC Number Contact phone Area code and number PROPORTIONATE ANNUAL SHARE OF CREDIT AVAILABLE TO EACH INSURER...
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