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W,-32 1969 <br /> <br />(I/We) do hereby swear under penalty of perjury that the <br />foregoing statements are true and correct. <br /> <br /> Date Applicant <br /> <br />SUBSCRIBED AND SWORN to before me this day of <br /> <br />(Notary Seal) <br /> <br /> Notary Public in and for the State of <br /> <br /> My Commission Expires: <br /> <br /> <br />