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Iciary Mr. Mrs. Ms Usual First Name and Initial Social Insurance Number Last Name Miss Province or Territory Address - No., Street, Apt., P.O. Box, R.R. and City Country - If other than Canada Postal Code Please note that, to be considered incapable of managing his/her own affairs, a person must be suffering from severe mental impairment or a physical illness or impairment. Does the person named above have: 1. Good general knowledge of what is happening to his/her money or investment.

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