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Get Nc Dss-5189 2003

______, declare: 1. That I was born on the _________ day of __________________, _________, and have a permanent address at _______________________________________________________________________________________________; 2. That I am of sound mind and in full possession of my mental faculties; 3. That I am the [mother] [father] of _______________________________________________, a __________ (Original Name of Child) (Sex) child, born on the ________day of ____________________, ______, in _.

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