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___, who, having been being first duty sworn by the undersigned Notary Public, deposes and says: 1. My full legal name is ____________________________________________. 2. My date of birth is ________________________. 3. My Social Security number is________________________________ 4. My driver’s license number is_______________________________. 5. My current address is Street Address ________________________________ City ___________________________ State ___________ Zip Code _________.

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