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DIAGNOSIS: RFC ASSESSMENT IS FOR: Current Evaluation SECONDARY DIAGNOSIS: Date Last Insured: OTHER ALLEGED IMPAIRMENTS: (Date) Date 12 Months After Onset: (Date) Other (Specify): PRIVACY ACT/PAPERWORK ACT NOTICE: The information requested on this form is authorized by Section 223 and Section 1633 of the Social Security Act. The information provided will be used in making a decision of this claim. Failure to complete this form may result in a delay in processing the claim. Informa.

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