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LAIMANT INFORMATION Claimant's Name Spouse's Name Check here if spouse is deceased Claimant's Social Security Number Spouse's Social Security Number Name(s) of property owner(s) as shown on property tax bill/receipt if different than claimant Mailing Address City, State & Zip Code Claimant's Date of Birth Spouse's Date of Birth Daytime Telephone Number Municipality PART II - FILING STATUS 1. I certify that I am: (Check One Box Only) A. A Claimant, age 65 or older as of December 31.

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