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Cial Security. Number E-mail Address Zip Code Telephone Number D D I am aware that federal law provides for Imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. I attest, under penalty of perjury, that I am (check one of the following): D A citizen of the United States D A noncitizen national of the United States (See instructions) D A lawful permanent resident (Alien Registration Number/USCIS Number): - -- - - - - --.

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