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SUBSCRIBED AND SWORN to before me this day of 20 in Issued at Doc. No.. No.. Book No.. Series of Affix P30.oo Documentary Stamp Tax Date Received: (MM-DD-YYYY-OOOO/) Applicant exhibited to me his/her on (Government Issued ID and No.) NOTARY PUBLIC (To be filled-out by the withholding agent/lone payor) Received by: Signature over Age'"/ Pul'nr ...

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  Sworn, Subscribed, Subscribed and sworn

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