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PATIENT INFORMATION Last name:First:Is this your legal name? Q Yes Mr. q Mrs. q Ms. Middle initial:If not, what is your legal name? Marital status (circle one) Single(Former name):MarriedDate of birth:q
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You are required to fill out the form.
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Individuals and businesses are required to file the form.
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What is the purpose of are you required to?
The purpose of the form is to report certain information to the authorities.
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You must report income, expenses, and any relevant financial information.
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