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NOTE The reverse side of this form must be completed. Section A pertains to a PA corporation or a foreign corporation that operated wholly within Pennsylvania. Section B pertains to all other foreign corporations. Date of Incorporation or Certificate of Authority Account ID/Corp* Box Entity ID EIN Name of Corporation/Taxpayer I the Affiant was connected with the above corporation and have knowledge of its affairs. Said corporation ceased to transact business in Pennsylvania on or about Month Da ...

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