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Wendv Benincasa 04/02/53 <br /> <br />5450 Ximines Lane, Plymouth, MN 55442 <br /> (Address) q S~r e2~l~f-fl-~r Circle <br /> <br />(N~t~e) (Bit t~date) <br /> <br />(Addr ess) <br /> <br />(S~n[e/~ulder/O£ficer - Circle One) <br /> <br />(Blt ti~date) <br /> <br />(Adds ess <br /> <br />(Snarel~ider/Officer - Circle One) <br /> <br />(Naune) (Birthd~se) <br /> <br /> (Address) (Stm~eholdez/Officer - Circle Ca%e) <br /> <br />3) ~e ea~ of ~ec__m~_s==' ~ ~n~or mnar~nol~ers~' ' ' n~ed above citizens of <br /> <br />~ne U'.~ q~ Yes <br /> <br />If no, sta+~ tine circu~.st~-nces for each == - ~' ~ ' ' ' ~ _ <br />, -- c_~ice~/_na, eno~oe, who ~s not a <br /> <br />?~ nat,~a!ize~, state date ~-.nd D~ a~ of =~ ~ ~ <br />-- na~u_ a=iz~tion. <br /> <br /> Give ri.~e -=',"~ '~ ~' "' ' - s spouse. <br /> <br />. ~cer/Snareho!der S~ouse Address <br /> 5%50 Ximines Lane <br />Wendv K Benincasa Anthony = Ben~ncasa ~vmou~ MN 554z <br /> <br />Page 2 of 8 <br /> <br /> <br />