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Dept. Use Only Jan. 1 - Dec. 31, 2010 or scal year ending , 20 USE LABEL OR PRINT OR TYPE PRIMARY NAME MI LAST NAME SPOUSE NAME MI LAST NAME YOUR SOCIAL SECURITY NUMBER SPOUSE S SOCIAL SECURITY NUMBER Important MAILING ADDRESS (Number and Street, P.O. Box or Rural Route) Important: You MUST enter your SSN(s) above CITY, STATE AND ZIP CODE FILING STATUS Check Only One Box ATTACH A COPY OF YOUR COMPLETE FEDERAL RETURN NONRESIDENT: (List State of residence).

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