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*If you are a student, are retired, or not-employed, please specify. If you are self-employed please include the name of your business in ‘Employer’ and a description of your occupation. Examples include “florist”, “attorney”, “plumber”. In ‘Employer,’ if you have an employer, please provide name and address. If not, please specify N/A.

Contributions are not tax deductible for federal income tax purposes.

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