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I Last Name Spouse s First Name MI Spouse s Last Name Home Address (Number and Street or Rural Route) City or Town State A. FILING STATUS Single or Married Filing Separately Check if you can be claimed as a dependent on another person s tax return. H. Amended return See instructions EXEMPTIONS: REGULAR 65 or OVER BLIND DEAF DISABLED E. Number of Dependent Children List all dependents on page 2, part 4. C. YOURSELF Married Filing Jointly B. Zip Code F. Number of Other.

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