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PATIENT INFORMATION REVISED 12/1/09 HOME PHONE WORK PHONE CELL EMAIL ADDRESS FAX NUMBER FULL NAME: MAILING ADDRESS: CITY STATE ZIP CODE BIRTHDATE: SSN: PATIENTS RELATIONSHIP TO INSURED: SELF SPOUSE
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What is revised 12109?
Revised 12109 is a tax form used to report certain information related to income and deductions.
Who is required to file revised 12109?
Individuals or entities with specific income and deduction items are required to file revised 12109.
How to fill out revised 12109?
Revised 12109 can be filled out manually or electronically, following the instructions provided on the form.
What is the purpose of revised 12109?
The purpose of revised 12109 is to accurately report income and deductions to the tax authorities.
What information must be reported on revised 12109?
On revised 12109, one must report detailed information about income sources, deductions, and any other relevant financial transactions.
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