By submitting this application using a current, valid Social Security number, I acknowledge that I have read the Privacy Act of 1974 and understand that I have the right to access information collected about me in connection with this application. If I am interested in receiving a decision on this application within 30 days, I understand that my response is voluntary, and that my response is not subject to penalty or the withholding of Social Security benefits. I understand that, if I submit incomplete information, an error may be made in my case and that the information I submit must meet the requirements of this application. This application is to be used for the sole and exclusive benefit of the claimant listed on this form. This form is not to be used to request or request the Commissioner to review (with this application or on any other matter) any other application which has not been received by the Commissioner. The claimant listed on this form is me and this form is made under my signature. Form No.
SSA-150 2003 free printable template
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If unknown show unknown. Amount for the period from Month Year Form SSA-150 7-2003 EF 07-2003 Destroy Prior Editions through. U.S. SSA Form ssa-ssa-150 Form Approved OMB No. 0960-0395 Social Security Administration MODIFIED BENEFIT FORMULA QUESTIONNAIRE NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON SOCIAL SECURITY NUMBER / NAME OF PERSON MAKING STATEMENT if other than above wage earner or self-employed person PRIVACY ACT STATEMENT Your response to ...
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