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DETERMINING YOUR ENTITLEMENT TO RETIREMENT
AMENDMENTS ADDITIONS AND CHANGES
STARTING YOUR CLAIM TO SOCIAL SECURITY BENEFITS
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Address Number agency ANNUAL REPORT answer appeal application approved charge area code basic benefit claim number coinsurance complete this form computation covered worker credits date month date of birth Department of Health disability benefits divorced spouse eligible for benefits employer enrollment Enter name entitled to benefits exempt amount exempt months Explain in Remarks Federal HCFA Hospital Insurance INSIDER TIP INSURANCE BENEFITS marriage medical insurance Medigap ment MIDDLE INITIAL monthly benefit Monthly Earnings Name of City Number and street office has records P.O. BOX paid payments person premium quarters of coverage reached 62 receive reduction REPORT OF EARNINGS request retirement benefits Routing Transit self-employed self-employment Signature block Social Security Act Social Security Administration Social Security benefits Social Security Number Social Security office Social Security taxes Supplemental Security Income Survivors taxable TELEPHONE NUMBER Vital Records widow or widower write ZIP Code