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Get SSA-11-BK 2009

Name of the institution (b) Enter the EIN of the institution INFORMATION ABOUT INDIVIDUALS APPLYING TO BE REPRESENTATIVE PAYEE 12. Enter: YOUR NAME DATE OF BIRTH SOCIAL SECURITY NUMBER ANY OTHER NAME YOU HAVE USED OTHER SSN'S YOU HAVE USED 13. How long have you known the claimant? 14. If the claimant lives with you, who takes care of the claimant when work or other activity takes you away from home? What is his/her relationship to the claimant? 15. (a) Main source of your income Employed.

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