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State :
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Date of Birth :
MM/dd/yyyy
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Wage Type (1) :
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W2 (Wage Earner)
1099 (Independent Contractor)
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Client Pay-Type :
-None-
W-2 Wage Earner
1099
W2 + 1099
Co-Client Pay Type :
-None-
W-2 Wage Earner
1099
W2 + 1099
Client Gross Pay :
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Automobile Payment(s) :
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Explanation of Hardship :