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Y No. (Example: 123-45-6789) 4. Spouse s Social Security No. (Example: 123-45-6789) Home Address (Number, Street, or P.O. Box) City or Town State FILING STATUS Single Married Filing Jointly ZIP Code Married Filing Separately * 5. On Original Return ................ ..................... 6. On This Return ................ ..................... * If married, filing separately, enter Spouse s full name: INCOME, ADDITIONS AND DEDUCTIONS A. On Original Return B. Net Change 7. 8.

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