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Get SSA-789-U4 2015

EITHER THE CLAIMANT OR REPRESENTATIVE SHOULD SIGN - ENTER ADDRESSES FOR BOTH CLAIMANT SIGNATURE SIGNATURE OR NAME OF CLAIMANT'S REPRESENTATIVE STREET ADDRESS. REPRESENTATIVE'S ADDRESS CITY TELEPHONE NUMBER STATE ZIP CODE CITY DATE TELEPHONE NUMBER STATE ZIP CODE DATE Witnesses are required ONLY if this form has been signed by mark (X). If signed by mark (X), two witnesses to the signing who know the person requesting reconsideration must sign below, giving their full addresses. 1. SI.

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