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1-2014 Middle c. OWCP File Number b. Mailing Address ( Including City State, ZIP Code ) d. Date of Injury Month Day Year E-Mail Address (Optional) SECTION 2 e. Social Security Number f. Telephone No./FAX No. Compensation is claimed for: Inclusive Date Range From To Intermittent? Yes No a. Leave without pay b. Leave buy back Yes No c. Other wage loss; specify type, such as downgrade, loss of Type: night differential, etc. Yes No d. Schedule Award (Go to Section 4) Go to Secti.

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