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For mortgage interest paid acquisition or abandonment of secured property cancellation of debt contributions to an individual retirement arrangement IRA and generally payments other than interest and dividends you are not required to sign the Certification but you must provide your correct TIN. Signature of Vendor Representative or Individual Payee Date Title of Individual Signing Form for Company Name same as above OMES-FORM-CP-042 04/2013 PAGE 1 OF 1. O. Box City State Zip Code Contact Name...

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