Get SSA HA-501-U5 2012
LAW JUDGE See (Take or mail the completed original to your local Social Security office, the Veterans Affairs Regional Privacy Act Notice Office in Manila or any U.S. Foreign Service post and keep a copy for your records) 1. CLAIMANT NAME CLAIMANT SSN 2. WAGE EARNER NAME, IF DIFFERENT 3. CLAIMANT CLAIM NUMBER, IF DIFFERENT 4. SPOUSE'S NAME, IF NOT WAGE EARNER SPOUSE'S CLAIM NUMBER OR SSN 5. I REQUEST A HEARING BEFORE AN ADMINISTRATIVE LAW JUDGE. I disagree with the determination made on .
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