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Social Security Number Home address (Number and Street, including apartment number or rural route) City, Town, Post Office County/Municipality Code FILING STATUS ON AMENDED RETURN As Originally Reported Yourself Spouse Domestic Partner . . . . 2. Married, filing joint return 3. Married, filing separate return 4. Head of household 5. Qualifying widow(er) Yourself Spouse . . . . . . . . . . . . . . . . 7. 8. Blind or Disabled Single Yourself Spouse . . . . . . . . . . .

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