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St name Social security number (see instructions) 2 Adoptive parent(s) address Street address, apartment number, or rural route number. If you have a P.O. box, see the instructions. City or town, state, and ZIP code (see instructions) 3 4 5 Child s name: 3a Last name As it will appear on your tax return 3b Last name Birth name if different and known . . Date of birth (month, day, year) Child s birth information Placement agency information Sign Here First name First name.

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