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US-DBC FORM 9275 SC

State Refund BSC Application Form
(State Refund Business or Self-Employed Cost Application Form)

Effective: March 04, 2024

Owned by: Office of U.S Department of Bank Card

OMB Control Number: 9275-1624

Related Programs: SRBSC

File size: 591KB

STATE REFUND BUSINESS OR SELF-EMPLOYED COST

APPLICATION FORM

Revised March 16, 2024

Control No.: 9275-1624
Expiration Date: 12/12/2024

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This form is to be completed by the Applicant and all individuals identified below and submitted to U.S Department of Bank Card.

Check one:

Applicant Ownership

List all owners of 20% or more of the equity of the Applicant. Attach a saparate sheet if necessary.

Employees at Time of Application
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Variations of this document

Version 4

Version 3

Version 2

Version 1

| Effective: 2024-05-13

| Effective: 2024-04-22

| Effective: 2024-04-08

| Effective: 2024-03-06

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Disclaimer: Translations are for informational purposes only. Applications must be submitted in English.

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