MO CDS

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Last name

b Social security number

a First name and middle initial

street Address 1

street Address 2

state

zip

city

single

married

head of household

head

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First Choice

Second Choice

Third Choice

total line 3

Multiply the number of qualifying children under age 17 by 2000

Add the amounts above for qualifying children and other dependents You may add to

other income not from jobs

deductions

extra with

Employees signature This form is not valid unless you sign it

Date

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2a

2b

2c

3

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