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Get SSA-1696-U4 2011

(e.g. a clerk), or other party or entity (e.g. a copying service) to receive information from your claim file on your representative's behalf for the duration of your claim. If you want to give your representative permission to do that, check the block to authorize this release. If you will have more than one representative, check the appropriate block and give the name of the individual you want to be your main representative. You must sign and date the form. Print or type your address, area c.

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