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Tion that you give us on this form will be used by the office that makes the disability decision on the child's claim. You can help them by completing as much of the form as you can. Print or type. Do not ask a doctor or hospital to complete this form. When we ask for certain numbers, such as dates and telephone numbers, we provide blocks to fill in. In these places, please print only one number in each block. For numbers under 10, put a zero in the first block for the month and/or d.

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