Form 214 - Earned Income Tax Return - 2010 Page 3
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1
2
3TAX
PENALTY
INTEREST
AMOUNT PAID
(A)
N ME
$
$
$
$
SSN
-
-
AMOUNT PAID
(B)
N ME
$
$
$
$
SSN
-
-
Place your payment and completed
Form 214-V in the same envelope with
your YATB Form 214 Earned Income
Tax Return. Mark the front of your
return envelope “PAYMENT ENCLOSED.”
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