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Paperwork Reduction Act
Statement

This information collection meets the requirements of 44
U.S.C. 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You
do not need to answer these questions unless we display a valid Office of
Management and Budget (OMB) control number. The OMB control number for this form
is 0960-0596; expiration date 09/30/2012. We estimate it will take about 10
minutes to read the instructions, gather the facts, and answer the questions.
You may send comments on our time estimate to SSA, 1338 Annex Building,
Baltimore, MD 21235-0001. Send only comments on our time estimate to
this address, not the completed form.

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