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Get SSA-1696-U4 2005

Wage Earner (If Different) Social Security Number Form Approved OMB No. 0960-0527 APPOINTMENT OF REPRESENTATIVE Part I , I appoint this person, (Name and Address) to act as my representative in connection with my claim(s) or asserted right(s) under: Title II Title XVI Title XVIII Title VIII (RSDI) (SSI) (Medicare Coverage) (SVB) This person may, entirely in my place, make any request or give any notice; give or draw out evidence or information; get information; and receive any notice in c.

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