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Your help is greatly appreciated. On the chart on page 3 list all wages received by this employee during the month s of Beginning Month MM DD YYYY Ending or current Month MM DD YYYY through Telephone No. inc. area code Signature HHSC Staff EMPLOYER PLEASE COMPLETE AND RETURN PAGES 2 3 Form H1028-A-FTI / 12-2010 Page 2 / 12-2010 Aged and Disabled Programs PLEASE COMPLETE AND RETURN PAGES 2 AND 3 ONLY Employee Name...
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