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R HAVING BEEN UNEMPLOYED MORE THAN FOUR (4) WEEKS. 2. YOU MUST COMPLETE ALL ITEMS OF PART A THE CLAIMANT S STATEMENT . BE ACCURATE. CHECK ALL DATES. 3. BE SURE TO DATE AND SIGN YOUR CLAIM (SEE ITEM 12). IF YOU CANNOT SIGN THIS CLAIM FORM, YOUR REPRESENTATIVE MAY SIGN IT IN YOUR BEHALF. IN THAT EVENT, THE NAME, ADDRESS AND REPRESENTATIVE S RELATIONSHIP TO YOU SHOULD BE NOTED UNDER THE SIGNATURE. 4. DO NOT MAIL THIS CLAIM UNLESS YOUR HEALTH CARE PROVIDER COMPLETES AND SIGNS PART B.

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