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/ / Month Day Year LEGAL RESIDENCE: HOUSE, STREET, APT. NO. or ROUTE AND BOX NO. CITY STATE ENGLISH (INGL S) ZIP CODE SPANISH (ESPA OL) I, the undersigned, make oath in due form of law that Yo, quien subscribe, presto el debido juramento de acuerdo no Social Security Number has ever been issued to con la ley, que nunca me ha sido emitido, por parte del me.

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