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Get Omb No 0960 0289

ORK ACT statement on reverse and the statements below. Then print, write, or type your response to the statements in the space provided below. If you need additional space, attach a separate page to this form. NAME OF DECEASED CLAIMANT CLAIM FOR WAGE EARNER'S NAME (Leave blank if same as above) SOCIAL SECURITY NUMBER I have been informed that the claimant had requested a hearing but died before action on the request was completed. I understand that the deceased claimant's request for hearin.

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