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14 State winnings City or town province or state country and ZIP or foreign postal code 15 State income tax withheld For Privacy Act and Paperwork Reduction Act Notice see the 2016 General Instructions for Certain Information Returns. 16 Local winnings File with Form 1096 17 Local income tax withheld 18 Name of locality Copy A For Internal Revenue Service Center Under penalties of perjury I declare that to the best of my knowledge and belief the name address and taxpayer identification number...
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