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Ast Name Spouse s Social Security Number Present Home Address (Number and street, including apartment number or rural route) Daytime Telephone Number ( City, Town or Post Office State If you want $5.00 ($10.00 if a joint return) to go Zip Code ) City or Town of Legal Residence If you wish the 1st $2.00 ($4.00 if a joint return) to be paid to a ELECTORAL Yes specific party, check the box and fill in the name of the political to this fund, check here. (See instructions. This CONTRIBUT.

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