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R Relative - Specify (e) Legal Representative (f) Board and Care Home Operator (g) Other Individual - Specify IF (b), (c), (d), or (e) ABOVE CHECKED, GO ON TO QUESTION 12 Form SSA-11-BK (5-2003) EF (5-2003) Page 2 YES NO INFORMATION ABOUT INSTITUTIONS, AGENCIES AND BANKS APPLYING TO BE REPRESENTATIVE PAYEE 10. (a) Enter the name of the institution (b) Enter the EIN of the institution 11. Is the claimant indebted to your institution for past care and maintenance? YES NO If YES, giv.

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