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1107 Curtis BATAVIA singer. OR A:CF., C A 92867. P HONE: 71474:47444 FA.x:NT.7+l7 320LocationCode :Date ReportedTime Reported/A Infirm action Report DO NOT TRITE IN SHADED AREASMidd LE NamellnitialFirst
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Information such as assets, liabilities, income, and gifts must be reported on this form.
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