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First Name: Social Security Number: I certify under penalty of perjury that: Middle Name: Maiden Name: I am a citizen of the United States and I have a valid US Driver License or US State ID. License/State ID Number: State: I am a citizen of the United States currently living outside the United States and do not have a valid US Drivers License or US State ID. Please attach a legible copy of your valid passport or other documentation to verify you are a legal citizen of the United States. I.

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