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Get SSA-16-BK 2010

ILITY INSURANCE BENEFITS I apply for a period of disability and/or all insurance benefits for which I am eligible under Title II and Part A of Title XVIII of the Social Security Act, as presently amended. 1. PRINT your name FIRST NAME, MIDDLE INITIAL, LAST NAME u 2. 3. Enter your Social Security Number u Check (X) whether you are u / 4. If this claim is awarded, do you want a password to use SSA's Internet/phone service? / Male Female Yes No Answer question 5 if English is not you.

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