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USE BLACK INK ONLY 13A. SIGNATURE OF APPLICANT 13C. DATE SIGNED MM/DD/CCYY 13D. ADDRESS STREET and NUMBER STATE REGISTRAR USE ONLY 13B. 6. The applicant must sign in Item 13A print his/her name in Item 13B enter the date signed in Item 13C and complete the address information in Items 13D 13G. 7. Cdph. ca.gov. Enclosed is the fee of for filing the amendment and one certified copy of the newly amended record. This form becomes a part of the original record type or print clearly in black ink...
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