Name:* Employer Name (if applicable): Phone:* Email:* Address:*
City, State, Zip:* County:* DOB:* Gender:* MF Tobacco:* NY
Spouse: DOB: Gender: MF Tobacco: NY
Child 1: DOB: Gender: MF
Child 2: DOB: Gender: MF
Child 3: DOB: Gender: MF
Child 4: DOB: Gender: MF
Child 5: DOB: Gender: MF
Child 6: DOB: Gender: MF
Child 7: DOB: Gender: MF
Child 8: DOB: Gender: MF
Child 9: DOB: Gender: MF
Child 10: Gender: MF DOB:
Child 11: Gender: MF DOB:
Child 12: Gender: MF DOB:
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