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  1. #5690
  2. @001 Please state the declarant's name:
  3. @002 Please state the declarant's city of residence:
  4. @003 Please state the declarant's county of residence:
  5. @004 Please state the declarant's state of residence:
  6. @005 Please state a designee, if any:
  7. @006 Please state designee's city and state of residence: