Get SSA-789-U4 2012
It is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both. CLAIMANT SIGNATURE EITHER THE CLAIMANT OR REPRESENTATIVE SHOULD SIGN - ENTER ADDRESSES FOR BOTH SIGNATURE OR NAME OF CLAIMANT'S REPRESENTATIVE STREET ADDRESS. CITY REPRESENTATIVE'S ADDRESS STATE TELEPHONE NUMBE.
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