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One leaf, typewritten in blue ink on the front side and handwritten in pencil on the reverse side. The document is in good physical condition. The document was laminated. The upper right corner, the lower right corner, and the lower left corner were folded into the laminate. There are three minor tears at the top edge. There is some minor fraying at the lower right edge. There is minor staining of unknown origin throughout the document. The word "copy" was handwritten in pencil at the upper right corner and then later erased. The document was folded vertically in half.

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