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Get SSA-2490-BK 2004

3) Type of Industry self-employment activity or business (4) Social Insurance (5) Name of Agency to which Number used contributions paid while working (b) Use columns (1) - (4) to enter information about the worker's periods of coverage under the foreign social insurance system which are not based on employment or self-employment (e.g., coverage for voluntary contributions, deemed or equivalent coverage, periods of military service, illness, etc.) (1) Dates Covered (From - To) (2) Type of cov.

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