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EFTA00175998
ess Pox number (340) 775-2528 • Il i, En I Enpbyer Idertfattiorl 'Viable 1 66-0585379 2 Sochi eaturlW number a Total number Of forms 1 4 Vodral Mara VN eithheld $ 6 Total mann repotted ail% thIS Form1026 `$25r 000. op ,_ Enter an "X" In only one boa below to indicate the type of form being filed
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