Please fill in all the mandatory fields (marked by *)

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* For verification purposes only pursuant to 18 U.S.C. §§ 2256 et seq.
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* For verification purposes only pursuant to 18 U.S.C. §§ 2256 et seq.
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RATE THE CURRENT STATE OF YOUR RELATIONSHIPS (1 BEING WORST AND 5 BEING BEST).
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* For verification purposes only pursuant to 18 U.S.C. §§ 2256 et seq.
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ON A SCALE ON 1 TO 5 (1 IS MOST FALSE AND 5 IS MOST TRUE), PLEASE ANSWER FOR THE STATEMENTS BELOW:
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