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Formation unless it displays a currently valid OMB control number. Part A - Employee 2. Social Security Number 3. OWCP file number for original injury 1. Name of employee (Last, First, Middle Initial) 4. Date of Birth Mo./Day/Yr. OMB No. 1240-0009 Expires: 11-30-2020 6. Home telephone 5. Sex Male Female 7. Home mailing address (include street address, city, state, and ZIP code). See instructions for address requirement. 8. Dependents Spouse Child/Children under 18 years City State 9.

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