I Social Security Administration Please read the back of the last copy before you complete this form. Name Claimant Print or Type Wage Earner if Different Form Approved OMB No. 0960-0527 APPOINTMENT OF REPRESENTATIVE Part I I appoint this person Name and Address to act as my representative in connection with my claim s or asserted right s under Title 11 RSDI Title XVI SSI Title IV FMSHA Black Lung Medicare Coverage SVB This person may entirely in my place make any request or give any notice...
omb no 0960 0527

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