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Continued on Page 2 Form SSA-4734-BK 12-2004 ef 12-2004 Formerly SSA-4734-U8 Use prior editions Page 1 A. FORM APPR0VED OMB NO. 0960-0431 PHYSICAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT SOCIAL SECURITY NUMBER CLAIMANT NUMBERHOLDER IF CDB CLAIM PRIMARY DIAGNOSIS - RFC ASSESSMENT IS FOR Current Evaluation SECONDARY DIAGNOSIS Date Last Insured OTHER ALLEGED IMPAIRMENTS Date 12 Months After Onset Other Specify PRIVACY ACT NOTICE The information requ.

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