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L sheet(s) if OMB NO. necessary. See reverse side for additional instructions. 1105-0008 1. Submit To Appropriate Federal Agency: 2. Name, Address of claimant and claimant's personal representative, if any. (See instructions on reverse.) (Number, street, city, State and Zip Code) 3. TYPE OF EMPLOYMENT 4. DATE OF BIRTH 5. MARITAL STATUS 6. DATE AND DAY OF ACCIDENT MILITARY 7. TIME (A.M. or P.M.) CIVILIAN 8. Basis of Claim (State in detail the known facts and circumstances attending the dama.

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