Statement of Claimant or Other Person - The United States ...
STATEMENT OF CLAIMANT OR OTHER PERSON. Form Approved OMB No. 0960-0045 Name of Wage Earner, Self-employed Person, or SSI Claimant. Social Security Number Name of Person Making Statement (If other than above wage earner, self-employed person, or SSI claimant) Relationship to Wage Earner, Self-Employed Person, or SSI Claimant ................
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