Form 2481 - Notice To Make Special Deposits Of Taxes Form Page 2

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Certificate of Delivery
of Form 2481
(Under section 7512, Internal Revenue Code)
I hereby certify that the original of this notice
was delivered in hand to:
Name and Title
at
on
a.m. p.m.
Place of Delivery
Revenue Officer (Signature)
Receipt of original acknowledged:
Signature
Title
Date

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