Joint Industry Standard: Moisture/Reflow Sensitivity Classification For Nonhermetic Solid State Surface Mount Devices
Joint Industry Standard: Moisture/Reflow Sensitivity Classification For Nonhermetic Solid State Surface Mount Devices
July 2002
Supersedes IPC/JEDEC J-STD-020A
April 1999
JOINT
INDUSTRY
STANDARD
Moisture/Reflow
Sensitivity Classification
for Nonhermetic
Solid State Surface
Mount Devices
NOTICE JEDEC standards and publications contain material that has been
prepared, reviewed, and approved through the JEDEC Board of
Directors level and subsequently reviewed and approved by the JEDEC
legal counsel.
JEDEC IPC
Solid State Technology Association 2215 Sanders Road
2500 Wilson Boulevard Northbrook, IL 60062-6135
Arlington, VA 22201-3834 Phone 847.509.9700
Phone 703.907.7560 Fax: 847.509.9798
Fax 703.907.7583
Please use the Standard Improvement Form shown at the end of this
document.
Copyright 2002. JEDEC, Arlington, Virginia, and IPC, Northbrook, Illinois. All rights reserved under both international and Pan-
American copyright conventions. Any copying, scanning or other reproduction of these materials without prior written consent of
the copyright holders is strictly prohibited and constitutes infringement under the Copyright Law of the United States.
IPC/JEDEC J-STD-020B
ASSOCIATION CONNECTING
ELECTRONICS INDUSTRIES ®
Moisture/Reflow
Sensitivity Classification
for Nonhermetic
Solid State Surface
Mount Devices
ii
July 2002 IPC/JEDEC J-STD-020B
Table of Contents
1 PURPOSE ................................................................. 1 6 CRITERIA .................................................................. 6
1.1 Scope .................................................................... 1 6.1 Failure Criteria ..................................................... 6
1.2 Background .......................................................... 1 6.2 Criteria Requiring Further Evaluation ................ 6
6.2.1 Delamination ........................................................ 7
2 APPLICABLE DOCUMENTS ................................... 1
2.1 Electronic Industries Alliance (EIA-JEDEC) ..... 1 6.2.1.1 Metal Leadframe Packages ................................. 7
2.2 IPC ....................................................................... 2 6.2.1.2 Substrate Based Packages ................................... 7
6.3 Failure Verification .............................................. 7
2.3 Joint Industry Standards ...................................... 2
7 MOISTURE/REFLOW SENSITIVITY
3 APPARATUS ............................................................. 2
CLASSIFICATION ..................................................... 7
3.1 Temperature Humidity Chambers ....................... 2
8 OPTIONAL WEIGHT GAIN/LOSS ANALYSIS ........ 8
3.2 Solder Reflow Equipment ................................... 2
8.1 Weight Gain ......................................................... 8
3.2.1 Full Convection (Preferred) ................................. 2
8.2 Absorption Curve ................................................. 8
3.2.2 Infrared ................................................................. 2
8.2.1 Read Points .......................................................... 8
3.3 Ovens ................................................................... 2
8.2.2 Dry Weight ........................................................... 8
3.4 Microscopes ......................................................... 2
8.2.3 Moisture Soak ...................................................... 8
3.4.1 Optical Microscope .............................................. 2
8.2.4 Readouts ............................................................... 8
3.4.2 Scanning Acoustic Microscope ........................... 2
8.3 Desorption Curve ................................................. 8
3.5 Cross-Sectioning .................................................. 2
8.3.1 Read Points .......................................................... 8
3.6 Electrical Test ...................................................... 2
8.3.2 Baking .................................................................. 8
3.7 Weighing Apparatus (Optional) ........................... 2
8.3.3 Readouts ............................................................... 8
4 CLASSIFICATION/RECLASSIFICATION ................. 3
9 ADDITIONS AND EXCEPTIONS ............................. 9
4.1 Reclassification .................................................... 3
5 PROCEDURE ............................................................ 4
Annex A ..................................................................... 10
5.1 Sample Requirements .......................................... 4
5.1.1 Reclassification (qualified package without
additional reliability testing) ............................... 4
5.1.2 Classification/Reclassification ............................. 4 Figures
5.2 Initial Electrical Test ............................................ 4 Figure 5-1 Classification Reflow Profile ................................ 6
5.3 Initial Inspection .................................................. 4
5.4 Bake ..................................................................... 4
5.5 Moisture Soak ...................................................... 4
5.6 Reflow .................................................................. 4 Tables
5.7 Final External Visual ........................................... 4 Table 4-1 Package Peak Reflow Temperatures .................. 3
5.8 Final Electrical Test ............................................. 4 Table 5-1 Moisture Sensitivity Levels .................................. 5
5.9 Final Acoustic Microscopy .................................. 4 Table 5-2 Classification Reflow Profiles .............................. 5
iii
IPC/JEDEC J-STD-020B July 2002
iv
July 2002 IPC/JEDEC J-STD-020B
1 PURPOSE
The purpose of this standard is to identify the classification level of nonhermetic solid state surface mount devices (SMDs)
that are sensitive to moisture-induced stress so that they can be properly packaged, stored, and handled to avoid damage
during assembly solder reflow attachment and/or repair operations.
This standard may be used to determine what classification/preconditioning level should be used for SMD package qualifi-
cation. Passing the criteria in this test method is not sufficient by itself to provide assurance of long-term reliability.
1.1 Scope This classification procedure applies to all nonhermetic solid state Surface Mount Devices (SMDs) in packages,
which, because of absorbed moisture, could be sensitive to damage during solder reflow. The term SMD as used in this
document means plastic encapsulated surface mount packages and other packages made with moisture-permeable materials.
The categories are intended to be used by SMD producers to inform users (board assembly operations) of the level of mois-
ture sensitivity of their product devices, and by board assembly operations to ensure that proper handling precautions are
applied to moisture/reflow sensitive devices. If no major changes have been made to a previously qualified SMD package,
this method may be used for reclassification according to 4.1.
This standard cannot address all of the possible component, board assembly and product design combinations. However, the
standard does provide a test method and criteria for commonly used technologies. Where uncommon or specialized compo-
nents or technologies are necessary, the development should include customer/manufacturer involvement and the criteria
should include an agreed definition of product acceptance.
SMD packages classified to a given moisture sensitivity level by using Procedures or Criteria defined within any previous
version of J-STD-020, JESD22-A112 (rescinded), IPC-SM-786 (rescinded) do not need to be reclassified to the current revi-
sion unless a change in classification level or a higher peak reflow temperature is desired.
Note: If the procedures in this document are used on packaged devices that are not included in this specification’s scope,
the failure criteria for such packages must be agreed upon by the device supplier and their end user.
1.2 Background The vapor pressure of moisture inside a nonhermetic package increases greatly when the package is
exposed to the high temperature of solder reflow. Under certain conditions, this pressure can cause internal delamination of
the packaging materials from the die and/or leadframe/substrate, internal cracks that do not extend to the outside of the
package, bond damage, wire necking, bond lifting, die lifting, thin film cracking, or cratering beneath the bonds. In the most
severe case, the stress can result in external package cracks. This is commonly referred to as the ‘‘popcorn’’ phenomenon
because the internal stress causes the package to bulge and then crack with an audible ‘‘pop.’’ SMDs are more susceptible
to this problem than through-hole parts because they are exposed to higher temperatures during reflow soldering. The rea-
son for this is that the soldering operation must occur on the same side of the board as the SMD device. For through-hole
devices, the soldering operation occurs under the board that shields the devices from the hot solder.
2 APPLICABLE DOCUMENTS
JESD22-A120 Test Method for the Measurement of Moisture Diffusivity and Water Solubility in Organic Materials Used in
Integrated Circuits
JESD22-A113 Preconditioning Procedures of Plastic Surface Mount Devices Prior to Reliability Testing
1. www.jedec.org
1
IPC/JEDEC J-STD-020B July 2002
2.2 IPC2
J-STD-033 Standard for Handling, Packing, Shipping and Use of Moisture/Reflow Sensitive Surface Mount Devices
3 APPARATUS
3.1 Temperature Humidity Chambers Moisture chamber(s), capable of operating at 85°C/85% RH, 85°C/60% RH, 60°C/
60% RH, and 30°C/60% RH. Within the chamber working area, temperature tolerance must be ± 2°C and the RH tolerance
must be ± 3% RH.
3.2.1 Full Convection (Preferred) Full convection reflow system capable of maintaining the reflow profiles required by
this standard.
3.2.2 Infrared Infrared (IR)/convection solder reflow equipment capable of maintaining the reflow profiles required by this
standard. It is required that this equipment use IR to heat only the air and not directly impinge upon the SMD Packages/
devices under test.
Note: The moisture sensitivity classification test results are dependent upon the package body temperature (rather than the
mounting substrate and/or package terminal temperature).
3.4 Microscopes
3.4.1 Optical Microscope Optical Microscope (40X for external and 100X for cross-section exam).
3.4.2 Scanning Acoustic Microscope Scanning acoustic microscope with C-Mode and Through Transmission capability
and capable of measuring a minimum delamination of 5% of the area being evaluated.
Note 1: The scanning acoustic microscope is used to detect cracking and delamination. However, the presence of delami-
nation does not necessarily indicate a pending reliability problem. The reliability impact of delamination must be established
for a particular die/package system.
Note 2: Refer to IPC/JEDEC J-STD-035 for operation of the scanning acoustic microscope.
3.5 Cross-Sectioning Micro-sectioning equipment as recommended per IPC-TM-650, Methods 2.1.1, 2.1.1.2 or other
applicable document.
3.6 Electrical Test Electrical test equipment with capabilities to perform appropriate testing on devices.
3.7 Weighing Apparatus (Optional) Weighing apparatus capable of weighing the package to a resolution of 1 microgram.
This apparatus must be maintained in a draft-free environment, such as a cabinet. It is used to obtain absorption and des-
orption data on the devices under test (see Clause 8).
2. www.ipc.org
3. Current and revised IPC Test Methods are available through IPC-TM-650 subscription and on the IPC Web site (www.ipc.org/html/testmethods.htm).
4. www.jedec.org / www.ipc.org
2
July 2002 IPC/JEDEC J-STD-020B
4 CLASSIFICATION/RECLASSIFICATION
Refer to 4.1 for guidance on reclassification of previously qualified/classified SMDs.
Engineering studies have shown that thin, small volume SMD packages reach higher body temperatures during reflow sol-
dering to boards that have been profiled for larger packages. Therefore, technical and/or business issues normally require
thin, small volume SMD packages (reference Table 4-1) to be classified at higher reflow temperatures.
Note 1: Previously classified SMDs should only be reclassified by the manufacturer. Users should refer to the ‘‘Moisture
Sensitivity’’ label on the bag to determine at which reflow temperature the SMD packages were classified.
Note 2: Level 1 SMD packages should be considered to have a maximum reflow temperature of 220°C unless labeled as
capable of reflow at other temperatures.
Table 4-1 Package Peak Reflow Temperatures
Pkg. Thickness ≥2.5 mm or Pkg. Thickness <2.5 mm and
Reflow Conditions Pkg. Volume ≥350 mm3 Pkg. Volume <350 mm3
SnPb Eutectic Convection 225 +0/-5°C Convection 240 +0/-5°C
Pb Free Convection 245 +0/-5°C Convection 250 +0/-5°C
Note 1: Package volume excludes external terminals (balls, bumps, lands, leads) and or nonintegral heat sinks.
Note 2: The maximum component temperature reached during reflow depends on package thickness and volume. The use of convection reflow processes
reduces the thermal gradients between packages. However, thermal gradients due to differences in thermal mass of SMD packages may still exist.
Note 3: Components intended for use in a ‘‘lead-free’’ assembly process shall be evaluated using the ‘‘lead free’’ peak temperature and profiles defined in
Tables 4-1 and 5-2 whether or not lead free.
Note 4: It is possible that very large (≥1400 cm2) thick (≥2.5 mm) boards that use components with a wide range of thermal mass, and/or boards undergoing
rework, might have difficulty maintaining all component bodies below the maximum temperatures in this specification. In such cases, the MSL level
must be determined for the body temperature the component will attain.
4.1 Reclassification SMD packages previously classified to a moisture sensitivity level and reflow peak temperature may
be reclassified if the damage response (delamination/cracking) at the more severe condition for items listed in 6.1 and 6.2
is less than, or equal to the damage response at the original classification condition.
If no major changes have been made to a previously qualified SMD package, this method may be used for reclassification
to an improved level (longer floor life) at the same reflow temperature. The reclassification level cannot be improved by
more than one level without additional reliability testing. Reclassification to level 1 requires additional reliability testing.
If no major changes have been made to a previously qualified SMD package, this method may be used for reclassification
at a higher reflow temperature providing the moisture level remains the same or degrades to a more sensitive level.
No SMD packages classified as moisture sensitive by any previous version of J-STD-020, JESD22-A112 (rescinded), IPC-
SM-786 (rescinded) may be reclassified as nonmoisture sensitive (level 1) without additional reliability stress testing, e.g.,
JESD22-A113 and JESD47 or the semiconductor manufacturer’s in-house procedures.
To minimize testing, the results from a given SMD package may be generically accepted to cover all other devices which
are manufactured in the same package, using the same packaging materials (die attach, mold compound and or die coating,
etc.), with the die using the same wafer fabrication technology, and with die pad dimensions not greater than those quali-
fied.
The following attributes could affect the moisture sensitivity of a device and may require reclassification:
• Die attach material/process.
• Number of pins.
• Encapsulation (mold compound or glob top) material/process.
• Die pad area and shape.
• Body size.
• Passivation/die coating.
• Leadframe, substrate, and/or heat spreader design/material/finish.
• Die size/thickness.
• Wafer fabrication technology/process.
• Interconnect.
• Lead lock taping size/location as well as material.
3
IPC/JEDEC J-STD-020B July 2002
5 PROCEDURE
The recommended procedure is to start testing at the lowest moisture sensitivity level the evaluation package is reasonably
expected to pass (based on knowledge of other similar evaluation packages).
In the case of equipment malfunction, operator error or electrical power loss, engineering judgment shall be used to ensure
that the minimum intent/requirements of this specification are met.
5.1.1 Reclassification (qualified package without additional reliability testing) For a qualified SMD package being
reclassified without additional reliability testing select a minimum sample of 22 units for each moisture sensitivity level to
be tested. A minimum of two nonconsecutive assembly lots must be included in the sample with each lot having approxi-
mately the same representation. Sample units shall have completed all manufacturing processing required prior to shipment.
Sample groups may be run concurrently on one or more moisture sensitivity levels.
5.1.2 Classification/Reclassification Select a minimum sample of 11 units for each moisture sensitivity level to be tested.
A minimum of two nonconsecutive assembly lots must be included in the sample with each lot having approximately the
same representation. Sample units shall have completed all manufacturing processes required prior to shipment. Sample
groups may be run concurrently on one or more moisture sensitivity levels. Testing must be continued until a passing level
is found.
SMD packages should not be reclassified by the user unless approved by the supplier.
5.2 Initial Electrical Test Test appropriate electrical parameters, e.g., data sheet values, in house specifications, etc.
Replace any components, while maintaining the sample requirements of 5.1.2, which fail to meet tested parameters.
5.3 Initial Inspection Perform an external visual and acoustic microscope examination, on all components, to establish a
baseline for the cracking/delamination criteria in 6.2.1.
Note: This standard does not consider or establish any accept/reject criteria for delamination at initial/time zero inspection.
5.4 Bake Bake the sample for 24 hours minimum at 125 +5/-0°C. This step is intended to remove moisture from the
package so that it will be ‘‘dry.’’
Note: This time/temperature may be modified if desorption data on the particular device under test shows that a different
condition is required to obtain a ‘‘dry’’ package when starting in the wet condition for 85°C/85% RH (see 8.3).
5.5 Moisture Soak Place devices in a clean, dry, shallow container so that the package bodies do not touch or overlap
each other. Submit each sample to the appropriate soak requirements shown in Table 5-1. At all times parts should be
handled using proper ESD procedures in accordance with JESD 625.
5.6 Reflow Not sooner than 15 minutes and not longer than 4 hours after removal from the temperature/humidity cham-
ber, subject the sample to 3 cycles of the appropriate reflow conditions as defined in Table 5-2 and Figure 5-1. If the tim-
ing between removal from the temperature/humidity chamber and initial reflow cannot be met then the parts must be rebaked
and resoaked according to 5.4 and 5.5. The time between reflows shall be 5 minutes minimum and 60 minutes maximum.
5.7 Final External Visual Examine the devices using an optical microscope (40X) to look for external cracks.
5.8 Final Electrical Test Perform appropriate electrical testing on all devices, e.g., data sheet values, in-house specifica-
tions, etc.
5.9 Final Acoustic Microscopy Perform scanning acoustic microscope analysis on all devices.
4
July 2002 IPC/JEDEC J-STD-020B
5
IPC/JEDEC J-STD-020B July 2002
tp
Tp Critical Zone
TL to Tp
Ramp-up
TL
Temperature
Tsmax tL
Tsmin
ts Ramp-down
Preheat
25
t 25oC to Peak
Time
IPC-020b-5-1
6 CRITERIA
6.1 Failure Criteria If one or more devices in the test sample fail, the package shall be considered to have failed the tested
level.
A device is considered a failure if it exhibits any of the following:
a. External crack visible using 40X optical microscope.
b. Electrical test failure.
c. Internal crack that intersects a bond wire, ball bond, or wedge bond.
d. Internal crack extending from any lead finger to any other internal feature (lead finger, chip, die attach paddle).
e. Internal crack extending more than two-thirds (2/3) the distance from any internal feature to the outside of the package.
f. Changes in package body flatness caused by warpage, swelling or bulging visible to the naked eye. If parts still meet
co-planarity and standoff dimensions they shall be considered passing.
Note 1: If internal cracks are indicated by acoustic microscopy, they must be considered a failure or verified good using
polished cross sections through the identified site.
Note 2: For packages known to be sensitive to vertical cracks it is recommended that polished cross sections be used to
confirm the nonexistence of near vertical cracks within the mold compound or encapsulant.
Note 3: Failing SMD packages must be evaluated to a higher numeric level of moisture sensitivity using a new set of
samples.
Note 4: If the components pass the requirements of 6.1, and there is no evidence of delamination or cracks observed by
acoustic microscopy or other means, the component is considered to pass that level of moisture sensitivity.
6.2 Criteria Requiring Further Evaluation To evaluate the impact of delamination on device reliability, the semiconduc-
tor manufacturer may either meet the delamination requirements shown in 6.2.1 or perform reliability assessment using
JESD22-A113 and JESD47 or the semiconductor manufacturer’s in-house procedures. The reliability assessment may con-
sist of stress testing, historical generic data analysis, etc. Annex A shows the logic flow diagram for the implementation of
these criteria.
6
July 2002 IPC/JEDEC J-STD-020B
If the SMD Packages pass electrical tests and there is delamination on the back side of the die paddle, heat spreader, die
back side (lead on chip only) but there is no evidence of cracking, or other delamination, and they still meet specified
dimensional criteria, the SMD Packages are considered to pass that level of moisture sensitivity.
6.2.1 Delamination The following delamination changes are measured from pre-moisture soak to post reflow. A delami-
nation change is the change between pre- and post-reflow. The percent (%) delamination change is calculated in relation to
the total area being evaluated.
6.3 Failure Verification All failures should be analyzed to confirm that the failure mechanism is associated with moisture
sensitivity. If there are no reflow moisture-sensitive-induced failures in the level selected, the component meets the tested
level of moisture sensitivity.
If the acoustic microscope scans show failure to any of the criteria listed in 6.2.1, the SMD Packages shall be tested to a
higher numeric level of moisture sensitivity or subjected to a reliability assessment using JESD22-A113 and JESD47 or the
semiconductor manufacturer’s in-house procedures.
7
IPC/JEDEC J-STD-020B July 2002
8.1 Weight Gain Weight gain analysis (absorption) can be very valuable in determining estimated floor life (the time from
removal of a device from dry pack until it absorbs sufficient moisture to be at risk during reflow soldering). Weight loss
analysis (desorption) is valuable in determining the bake time required to remove excess moisture from a device so that it
will no longer be at risk during reflow soldering. Weight gain/loss is calculated using an average for the entire sample. It is
recommended that ten (10) devices be used in the sample.
Final weight gain = (wet weight - dry weight)/dry weight.
Final weight loss = (wet weight - dry weight)/wet weight.
Interim weight gain = (present weight - dry weight)/dry weight.
Interim weight loss = (wet weight - present weight)/wet weight.
‘‘Wet’’ is relative and means the package is exposed to moisture under specific temperature and humidity conditions.
‘‘Dry’’ is specific and means no additional moisture can be removed from the package at 125°C.
8.2.1 Read Points The X-axis (time) read points should be selected for plotting the absorption curve. For the early read-
ings, points should be relatively short (24 hours or less) because the curve will have a steep initial slope. Later readings may
be spread out further (10 days or more) as the curve becomes asymptotic. The Y-axis (weight gain) should start with ‘‘0’’
and increase to the saturated weight gain. Most devices will reach saturation between 0.3% and 0.4% when stored at 85
°C/85% RH. Use the formula in 8.1. Devices shall be kept at room ambient between removal from the oven or chamber and
weighing and subsequent reinsertion into the oven or chamber.
8.2.2 Dry Weight The dry weight of the sample should be determined first. Bake the sample for 48 hours minimum at 125
+5/-0 °C to ensure that the devices are dry. Within one (1) hour after removal from the oven, weigh the devices using the
optional equipment in 3.7 and determine an average dry weight per 8.1. For small SMDs (less than 1.5 mm total height),
devices should be weighed within thirty (30) minutes after removal from oven.
8.2.3 Moisture Soak Within one (1) hour after weighing, place the devices in a clean, dry, shallow container so that the
package bodies do not touch each other. Place the devices in the desired temperature/humidity condition for the desired
length of time.
8.2.4 Readouts Upon removal of the devices from the temperature/humidity chamber, allow devices to cool for at least
15 minutes. Within one (1) hour after removal from the chamber, weigh the devices. For small SMDs (less than 1.5 mm
total height), devices should be weighed within thirty (30) minutes after removal from the chamber. After the devices are
weighed, follow the procedure in 8.2.3 for placing the devices back in the temperature/humidity chamber. No more than two
(2) hours total time should elapse between removal of devices from the temperature/humidity chamber and their return to
the chamber.
Continue alternating between 8.2.3 and 8.2.4 until the devices reach saturation as indicated by no additional increase in
moisture absorption or until soaked to the maximum time of interest.
8.3 Desorption Curve A desorption curve can be plotted using devices that have reached saturation as determined in 8.2.
8.3.1 Read Points The suggested read points on the X-axis are 12 hour intervals. The Y-axis should run from ‘‘0’’ weight
gain to the saturated value as determined in 8.2.
8.3.2 Baking Within one (1) hour (but not sooner than fifteen (15) minutes) after removal of the saturated devices from
the temperature/humidity chamber, place the devices in a clean, dry, shallow container so that the package bodies do not
touch each other. Place the devices in the bake oven at the desired temperature for the desired time.
8.3.3 Readouts At the desired read point; remove the devices from the bake oven. Within one (1) hour after removal of
the devices from the bake oven, remove the devices from the container and determine their average weight using the optional
equipment in 3.7 and formula in 8.1.
8
July 2002 IPC/JEDEC J-STD-020B
Within one (1) hour after weighing the devices, place them in a clean, dry, shallow container so that the package bodies do
not touch each other. Return the devices to the bake oven for the desired time.
Continue until the devices have lost all their moisture as determined by the dry weight in 8.2.2.
9
IPC/JEDEC J-STD-020B July 2002
Annex A
Classification Flow
Pass NO
Electrical
Test?
YES
External Visual Inspection
YES
External
Cracks?
NO
Evaluate/Obtain Internal Damage Information
Acoustic Microscopy Images, Cross-sections, etc.
NO
Crack or
Delamination?
YES
Crack
NO or Delamination
Change (Other Than Heat
Spreader or Backside
Paddle)?
YES
Assess Crack by X-section or Other Means
FAIL
Crack
Criteria?
PASS
Reliability
YES
Assessment
Planned
NO
PASS
Delamination
Criteria
FAIL
Reliability Assessment
YES NO
Pass
Reliability?
PASS FAIL
Classification Classification
for Level Tested for Level Tested
IPC-J-STD-020b-a
10
Standard Improvement Form IPC/JEDEC J-STD-033A
The purpose of this form is to provide the Technical Committees of IPC and JEDEC with input from the industry
regarding usage of the subject standard. Individuals or companies are invited to submit comments to IPC and
JEDEC. All comments will be collected and dispersed to the appropriate committee(s).
If you can provide input, please complete this form and return to both associations:
IPC JEDEC
2215 Sanders Road 2500 Wilson Blvd.
Northbrook, IL 60062-6135 Arlington, VA 22201-3834
Fax: 847.509.9798 Fax: 703.907.7583
Submitted by:
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Address:
City/State/Zip Date: