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First name:
















SWORN STATEMENTS

I am the person, or the authorized agent of the person, whose name appears above.
The information I have provided is true, correct, and I am not requesting this information for any fraudulent, criminal, malicious, or otherwise unlawful purpose.
I understand and agree that this request will be processed in accordance with applicable law.

SIGNATURE

MM/DD/YYYY (e.g. "12/02/2021")
e.g. John P. Jones






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