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Get SSA-521 2012

(10-2012) Destroy Prior Editions OTHER (Attach special determination) OTHER (Specify) Additional Remarks: Privacy Act Statement Collection and Use of Personal Information Sections 202 (a), 205 (a), and 1872 of the Social Security Act, as amended, authorize us to collect this information. The information you provide will be used to cancel your application for benefits. The information you furnish on this form is voluntary. However, failure to provide the requested information may cause cont.

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