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)(A) Name Date of birth (mm/dd/yyyy) (Parent filling out this affidavit) SS Number Disclosure required on separate form Address (street) (town or city) (state) (zip) 1. Gross income from wages, salary, and/or self-employment Current employment information Employer Name: Address: Self-employed Required: I have attached copies of my most recent W-2 form and two (2) pay stubs, or tax return or 1099 form if self-employed. A. How much did you earn last year? $ B. How much do you currently ear.
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