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Get SSA-789-U4 2003

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. 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 STATE CITY TELEPHONE NUMBER ZIP CODE DATE STATE CITY TELEPHONE NUMBER ZIP CODE DATE Witnesses are r.

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