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Ifferent from above: Address 2 Social Security # Date of Birth E-Mail Address DOB Phone Social Security # Please complete the appropriate section below: IRS Inquiries Tax Year(s) Type of Tax Military or Veterans Affairs Inquiries VA File Number VA Regional Office Location Branch of Service Military Rank Where Stationed Period of Service Medicare Inquiries Are you a Provider? List your Contractor Are you attempting to enroll or re-enroll in Medicare? Which office are you currently correspon.

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