Form 984 - Ohio Department Of Taxation - 2007

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2007
Form 984
Rev. 10/06
Name of dealer
Address
This form must be completed by each dealer in support of Balance Sheet, line 2, for form 980.
Interest
Number
Rate or
Fair or Market Value
of Shares
Name of Investment
Class,
Book
at Close of Business
or Par
Value
and Due Date
if Stock
Value
Dec. 31, 2006
Signature

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