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His form, you may use Form 1040A if your total income was less than $5,000, consisting wholly of wages shown on Forms W-2, or of such wages and not more than $100 of other wages, dividends, and interest. Name ----------------------------------------------------------------------------------------(PLEASE PRINT. If this is a joint return of husband and wife, use first names of both) HOME ADDRESS Do not write in these spaces Serial No. (Cashier's Stamp) ---------------------------------------.

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