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AFFIDAVIT <br />STATE OF MINNESOTA 1 SS: <br />COUNTY OF RAMSEY <br />being first duly sworn <br />deposes and says + at (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 />1 <br />