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Get Ha 85 2014-2024

Esses must give their full address. 1. Signature of Witness 2. Signature of Witness Address (Number and Street, City, State, ZIP Code) Address (Number and Street, City, State, ZIP Code) Form HA-85 (01-2014) Page 1 SSN: Additional Remarks: FOR USE OF SOCIAL SECURITY ADMINISTRATION APPROVED NOT APPROVED BECAUSE SIGNATURE OF SSA EMPLOYEE Form HA-85 (01-2014) CLAIMANT DOES UNDERSTAND CONSEQUENCES TITLE Page 2 WITHDRAWAL WOULD HARM INTEREST OF CLAIMANT OR OTHER PARTIES ADMINISTRATIVE LA.

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