Name Jack Kress
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Joint Name Mary Kress
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Address 1168 Maple
Drive
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Address 1168
Maple Drive
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City/State/Zip Wayne
NE68787
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City/State/Zip Wayne
NE68787
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Date of Birth Feb. 6 1940
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Date of Birth June 21 1942
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Mother's Maiden Name Laura Jacobson
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Mother's Maiden Name Carolyn Hyde
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Occupation Doctor
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Occupation Nurse
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Home Phone Number 402-375-2003
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Home Phone Number 402-375-2003
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Daytime/Business Phone Number
xxx-xxx-xxxx
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Daytime/Business Phone Number
xxx-xxx-xxxx
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Social Security Number xxx-xx-xxxx
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Social Security Number xxx-xx-xxxx
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E-mail Address imadoc@smartnet.net
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E-mail Address imanurse@smartnet.net
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The social security number shown on this form is
my correct taxpayer identification number and I am
not subject to backup withholding.
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The social security number shown on this form is
my correct taxpayer identification number and I am
not subject to backup withholding.
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Signature Jack Kress
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Signature Mary Kress
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