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The document is a Care Provider Statement (Form OR-PS) from the Oregon Department of Revenue, used for recordkeeping related to the Working Family Household and Dependent Care credit. It requires care providers to report detailed information about payments received for caring for taxpayers' dependents during a specified tax year. The form includes sections for listing dependents, payment details, and additional information regarding the care provided. It also outlines instructions for both taxpayers and care providers on how to complete and submit the form along with necessary documentation.

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