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5-6789) Home Address (No., Street, P.O. Box or Rural Route) City or Town State FILING STATUS Single Married Filing Jointly ZIP Code Married Filing Separately * 5. On Original Return...... ...................... 6. On This Return............ ...................... * If married, filing separately, enter Spouse s name: ...................... ...................... INCOME, ADDITIONS and DEDUCTIONS A. On Original Return B. Net Change 7. 8. 9. 10. 11. 12. 13. 14. Adjusted gross inco.

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