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EXHIBIT B -5 <br />SOCIAL SECURITY VERIFICATION <br />CLAIMANT NAME DATE OF BIRTH <br />SOCIAL SECURITY # S.S. CLAIM # <br />ADDRESS <br />I do hereby authorize the Social Security Administration to furnish to the <br />information regarding the amount of the monthly payment made to me. <br />Signature: <br />Date: <br />Indicate information needed by checking spaces below: <br />The gross amount of the monthly social security benefit is $ <br />The amount deducted for Medicare is$ <br />The net amount of the social security check each month is $ <br />The above amount became effective <br />Montn Y ear <br />The monthly payment of the supplemental security income payment is $ <br />The above amount became effective <br />Month Year <br />Other information needed - please specify on reverse side. <br />Complete only if you are unable to verify information requested: <br />Claim Still Pending <br />No record based on identifying information <br />Other - see reverse side of form <br />SIGNATURE AND TITLE OF AUTHORIZED SOCIAL SECURITY OFFICIAL: <br />DATE <br />PLEASE RETURN FORM TO: <br />01- 351904.01 <br />B -11 <br />PHONE NUMBER <br />200109053 <br />