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Birth (mm/dd/yyyy) Citizenship/Nationality File Number A Female Family Name First Name U.S. Social Security No. (if any) City and Country of Birth All Other Names Used (include names by previous marriages) Date of Birth (mm/dd/yyyy) City and Country of Birth (if known) City and Country of Residence Father Mother (Maiden Name) First Name Current Husband or Wife (If none, so state) Family Name (For wife, give maiden name) Former Husbands or Wives (If none, so state) First Name Family.

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