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Get Changes You Need To Tell Us About If You Claim Benefits

T you think is relevant. Date of change / / Declaration I understand that if I knowingly give information that is incorrect or incomplete, my benefit may be stopped and I may be liable to prosecution or other action. I declare that the information I have given on this form is correct and complete as far as I know and believe. Signature Date / / office on For office use Form issued by Form received on / / / / Form issued / by / on / / Action required Action taken on / Ver.

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