Form SSA-821-BK Page 1 of 12 OMB No. 0960-0059 Social ...
important to fill out the form carefully and completely. Remember to sign and date the form. If you do not return this form, we may contact your employer or make our determination based on the evidence we have in our records. Some Information To Help You Complete This Form. Our records show these employers and yearly earnings for you. ................
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