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St Name, Middle Initial and Last Name 2 Filer's Social Security Number w w 1 3 Spouse's Social Security Number Office Use Home Address (No., Street, P.O. Box or Rural Route) State ZIP Code w City or Town 5 STATE Do you or your spouse, if filing a joint return, want $3 of your taxes to CAMPAIGN FUND go to this fund? This will not increase your tax or reduce your refund. 4 w w PLACE LABEL HERE IMPORTANT: This form is for people whose filing status is "single" or "married filing.

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