Taxpayer:
Spouse:
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Did Dependent Live with Taxpayer?
First Name
M
Last Name
Year of Birth
Dependent's Social Security Number
Relationship
No of Months in Home
Educ Expense
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Name
Street Address
City
State
Zip Code
EIN
Amount Paid
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Amount
Box 17 - State Income Tax
Box 18 - Local Wages
Box 19 - Local Income Tax
Box 20 - Locality Name
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Reimbursements from
Employer
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Memo___________________ _______________________
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