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99 �oss5g <br /> EXHIBIT B-4 <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 /> Month Year <br /> The gross amount of the monthly social security benefit 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 <br /> SECURITY OFFICIAL: <br /> DATE <br /> PHONE NUMBER <br /> PLEASE RETURN FORM TO: <br /> B-4-1 <br />