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5690.XXX
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1991-06-27
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311b
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7 lines
#5690
@001 Please state the declarant's name:
@002 Please state the declarant's city of residence:
@003 Please state the declarant's county of residence:
@004 Please state the declarant's state of residence:
@005 Please state a designee, if any:
@006 Please state designee's city and state of residence: