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Get Modified Benefit Formula Questionnaire

Form Approved OMB No. 0960-0561 Social Security Administration MODIFIED BENEFIT FORMULA QUESTIONNAIRE -- FOREIGN PENSION NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON U.S. SOCIAL SECURITY NUMBER NAME OF PERSON MAKING STATEMENT if other than above wage earner or self-employed person Privacy Act Statement Section 215 of the Social Security Act as amended authorizes us to collect the information on this form. The information you provide will be used t.

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