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J <br />AFFIDAVIT <br />STATE OF MI NNESOTA } <br />SS: <br />COUNTY OF RAMSEY } <br />, being first duly sworn <br />deposes and says that (he, she) lives at <br />In Little Canada, Minnesota; (he, she) is the owner and head of the household on these premises, <br />that (he, she) is presently receiving Retirement Survivors Insurance or Disability Insurance, under <br />the Social Security Act, 42 U.S.C. - S.S. 301, as amended. <br />Dated <br />NAME <br />ADDRESS <br />TEL. NO. <br />APT. NO . <br />FOR MOBLE HOME UNITS: <br />LOT NO . <br />MOBLE HOME UNIT NO. <br />Clerk's exhibit no. 666 <br />meeting 12-8-76 <br />