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QUANTITY (BARS)
WEIGHT (KG)
NAME
DATE OF BIRTH
CITY
STATE
ZIPCODE
NAME
NEW CO-OWNERS
DATE OF BIRTH
CITY
STATE
ZIPCODE
NAME
DATE OF BIRTH
CITY
STATE
ZIPCODE
STATEMENT OF APPLICANTS(s): This undersigned hereby certifies all of the above to be true and correct and
that names above are the new owners of the property and further certifies that they agree in every particular
SIGN
HERE