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Agent shall provide service to Agent s policyholders and/or assist Sub-Agents in servicing policyholders. Certify that FATCA code s entered on this form if any indicating that you are exempt from the FATCA reporting is correct. If returning kit by mail use address shown below If returning by fax use number 877 608-4634 Attn New Business 445 State Street Fremont MI 49349 AGT-ADA 1015 W-9 Form Rev. December 2014 Department of the Treasury Internal Revenue Service Request for Taxpayer...
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