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OMB No.: Expires: 1215-0103 08/31/2005 c. OWCP File Number b. Mailing Address (Including City, state, ZIP Code) d. Date of Injury Month Day Year e. Social Security Number E-Mail Address (optional) SECTION 2 Compensation is claimed for: a. b. f. Telephone No./FAX No. Inclusive Date Range TO From ( Intermittent? Yes Yes Yes Leave without pay Leave buy back Other wage loss; specify such as downgrade, loss of night differential, etc. Type: Schedule Award (Go to Section 4) C. d. - ) ).

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