N O 1 Y bian,,s..,,, S. 4A. DATE OPINFITH 18. /I UR TM SA MIDDLE E SC. STATE OF BIRTH USA) ' 60 SOCIAL SECURITY NO LA tki DIN NMIE 7A, RESIDENCE STATE MI 1 78 COUNTY 70. IF CITY OR WAGES RESIDENCE WITHIN CITY OR VILLAGE LIMITS? O IF NO, SPECIFY TOWN 7E STREET AND NUMBER OF RESIDENCE . I s ZIP C