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APPLICANT INFORMATION PATIENT AGREEMENT FORMER OFFICE USE ONLY Date Received: Verified By: Please write in print. First Name: Middle Initial: Last Name: Date of Birth: Street Address: City: State:
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{'form':'Form XYZ'}
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{'required_filers':['Individuals', 'Corporations', 'Partnerships', etc.']}
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{'instructions':'Fill out each section accurately and completely, attach supporting documentation, etc.'}
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{'purpose':'To report income, deductions, credits, etc. for tax purposes.'}
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{'required_information':['Income sources', 'Expenses', 'Tax credits', etc.']}
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