no. 4 OM( AITAW0 Opt no) (c)ly) (state) (slaw:Is) (7) SOCIAL SECURRY NO. Optional) (8)143HE TELEPHONE NO. (0) SEX F (10);RACETETHNIC ORIGIN w Di -American Indian/Alaskan Native 0 B-Black, Non-Hispanic • H-Hispanic 0 A-Asian/Pacific Islander 0 W-White, Non-Hispanic 0 M-Multlraclal Oh DATE OF WM 00414:0111/0 (12)PLACE OF BIRTH (co