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Get Benefit Claim For Attached Worker Form

ME MI LAST NAME 2. SOCIAL SECURITY NUMBER 3. MAILING ADDRESS CITY STATE 4. COUNTY OF RESIDENCE CODE 5. HISPANIC/LATINO (0) No ZIP CODE (1) Yes (9) Unknown 6. SEX 5a. RACE 7. DATE OF BIRTH (1) WHITE 8. ARE YOU A U.S. CITIZEN? Y 9. RETIREMENT PENSION N Y N (2) BLACK (3) AMERICAN INDIAN / ALASKAN NATIVE (4) ASIAN (6) MULTIPLE (7) OTHER MM / DD / YYYY 10. DURING THE PAST 2 YEARS HAVE YOU SERVED IN THE US MILITARY? (If NO FOR ITEM 8, OR YES FOR ITEM 9, COMPLETE.

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