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E.A. HAWSE HEALTH CENTERREGISTRATION FORM Behavioral Health (Please Print)Today's Date:NEW:UPDATED:PATIENT INFORMATION Patients last name:First:Middle: Mr. Mrs. Miss Ms. Marital Status: SingleMarDiv
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Div sep wid is a form used to report dividend separation and withholding information to the tax authorities.
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Information such as payer details, recipient details, amount of dividends paid, and the amount of taxes withheld must be reported on div sep wid.
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