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PATIENT DEMOGRAPHIC FORM (THIS FORM IS TO BE UPDATED YEARLY AND WITH ANY INFORMATION CHANGES) Patient Name: SS#: Date of Birth: SEX: M F Marital Status: S M D W Address: Apt. No.: City: State Zip
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This form is used for reporting income and tax information.
Individuals and businesses who have earned income throughout the year.
The form must be completed with accurate income and tax information.
The purpose of this form is to report taxable income to the government.
Income sources, deductions, and tax owed must be reported on this form.
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