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AFFIDAVIT <br />STATE OF MINNESOTA 1 <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 . N0. <br />FOR MOBLE HOME UNITS: <br />LCYT NO. <br />MOBLE HOME UNIT NO. <br />004 <br />