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T1)(11:H1111(11i trip ; i 11, _, I tlI111\' 1Assignment and Report 2. U.I. NUMBER (ORG. SEG. CODE, ASSIGNMENT NO., P.P.C.) 77303020170175B1B 3. PERMIT/LICENSE NUMBER 4a. TARGET DATE 4b. TARGET HOURS
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I i 11 i is a form used for reporting income generated from interest or dividends.
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