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STANDARD DENTAL
CLAIM FORM
UNIQUE NO.PART 1 DENTIST
P
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NT Smith
LAST NAMED
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TJohnGIVEN NAME123 Any StreetADDRESSAny CityCITYON
PROVINCEZ0Z
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POSTAL CODES PEC.PATIENTS OFFICE ACCT.
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Start by writing down the person's first name, also known as the given name.
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What is johngiven name?
John
Who is required to file johngiven name?
Individuals and entities with taxable income
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By providing accurate and complete information on the form
What is the purpose of johngiven name?
To report income and ensure compliance with tax laws
What information must be reported on johngiven name?
Income, deductions, credits, and other relevant tax information
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