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Dable Fee of $35.00) Checks returned for insufficient funds will be assessed a $40.00 service charge pursuant to O.C.G.A. 16-9-20. PART I:PERSONAL INFORMATION: 1. Name: LAST FIRST 3. Social Security #*: - - MIDDLE Date of Birth: M M MAIDEN - D D - Y Y Y Y *This information is authorized to be obtained and disclosed to state and federal agencies pursuant to O.C.G.A. 19-11-1 and O.C.G.A. 20-3-295, 42 U.S.C.A. 551 and 20 U.S.C.A. 1001. It may also be disclosed to the Na.

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