pouse's date Of DIM pendapral Spouse's Social Saari), number Mailing address (see instructions. page 13/Muni:sand Mater or PO be I 'velment number New York Statecounty of residence 288 WEST 4TH ST NY City. village. a pail oltce Stare MP cock, Country pt not u kW elates/ School ninny name NEW YORK NY 10014