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OF THE CITY OF NEW YORK 65 COURT STREET BROOKLYN NEW YORK 11201-4965 G Last Name MI XXX XX Active SSN Last 4 Digits Employee Identification Number Leave of Absence Employee Status Address Apt. Notary Public or Commissioner of Deeds If you have an official seal please affix it. OFFICIAL USE ONLY Type Direct Payments MAX LAD LAR Yes check yes if not on active payroll. I understand that any incorrect information provided will affect the transfer of my funds. ACKNOWLEDGEMENT Program...
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