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UNSHADED AREAS ONLY M.I. (1) LAST NAME (16) CITY (15) MARITAL STATUS R ACE C ODE SEX (S EE (M MALE) BEL OW ) (F FEMALE) (S SI NGLE) (M MARRIED) (X MARRIED CL AIMI NG SI NGLE) STATE (2) NUMBER OF W /H ALLOW . (2) ZIP CODE (5 OR 9) OR FOREIGN COUNTRY (13) FOR AGENCY USE ONLY ORGANIZATION ADDI TIONAL AMOUNT W HOLE DOLL ARS OLO (4) L2 (2) L3 (2) .00 I f yo u m ee t bo t h o f t h e ab o ve c o ndi t i o ns e nt er ye a r ef f ec t i ve an d "E X E MPT " . RACE CODES 1 W H I TE (.

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