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S A, B & C if: You did not receive a 2003 dividend. Social Security Number Date of Birth (Month-Day-Year) First Name M.I. Answer only parts B & C if: You were absent from Alaska for a total of 90 days or more during 2003. You are outside of Alaska today. Last Name I certify that the information I am supplying on and with this form is true. I understand that a false statement made on or with this form will subject me to the same penalties disclosed on my original application. Yo.

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