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Get SSA-7162-OCR-SM 2004

Sult in suspension of benefits. SIGN AND RETURN THIS FORM IN THE ENCLOSED ENVELOPE. SEE INSTRUCTIONS ENCLOSED. 1. Print your address here only if it is different from the one shown below. Telephone number at which you may be contacted during the day. 2. Enter current addresss here, or former address if you entered a new address above Enter Social Security Number of Worker: • Enter Name of Beneficiary: IF YOU ANSWER”YES” TO ANY OF THE QUESTIONS BELOW, PLEASE TURN THIS FORM OVER AND.

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