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NAME OF SPOUSE 6. DATE OF BIRTH OF SPOUSE 7. RELATIONSHIP 8. PLACE OF MARRIAGE (CITY & STATE OR COUNTRY) 9. DATE MARRIED 10. CITIZENSHIP OF SPOUSE 11. ADDRESS OF SPOUSE 12. DEP 13. NAME OF CHILD OR DEPENDENT 14. DATE OF BIRTH 15. RELATIONSHIP 16. ADDRESS (INCLUDE NAME OF CUSTODIAN IF OTHER THAN CLAIMANT) 18. NAME OF CHILD OR DEPENDENT 17. DEP 19. DATE OF BIRTH 20. RELATIONSHIP 21. ADDRESS (INCLUDE NAME OF CUSTODIAN IF OTHER THAN CLAIMANT) 23. NAME OF CHILD OR DEPENDENT 22. DEP 24..

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