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SSN.........................
First Name................
Last Name.................
Taxpayer
Date OF Birth............
Daytime....................
Evening....................
Cell..........................
Street Address...........
City.....
State.....
Zip Code.....
County.....
Middle Initial.............
Mailing Address
Cell..........................
Evening....................
Daytime....................
Date OF Birth............
Last Name.................
Middle Initial.............
First Name................
SSN.........................
Spouse
Folder Number
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