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_____/_____/_____ i hereby request that this child be exempted. This medical exemption is temporary. Each exemption a customer may claim on this form has special rules (see. The seller must keep a copy of the completed form on file. • the seller must keep this form.

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You May Be Requested To Sign By The Withholding Agent Even If Items 1, 4, Or.

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This Is Done By Reducing The Net.

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