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THIS FORM MUST BE FILLED IN. HAND-WRITTEN FORMS WILL NOT BE ACCEPTED!!!!!!!!!!! State of Louisiana Department of Health & Hospitals Louisiana Physical Therapy Board 104 Fair lane Drive, Lafayette,
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This form must be a tax form.
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Individuals or entities earning income.
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By providing accurate and complete information.
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To report income and taxes.
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Income, deductions, and credits.
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