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NUMBER B.I.C. (OPTIONAL) Name of Person Entitled to the Benefits Telephone Number: THIS BOX IS FOR ALLOTMENT OF PAYMENT ONLY (if applicable) Type PAYEE CERTIFICATION I (beneficiary or representative payee) certify that I have read and understand the back of this form. In signing this form, I authorize the Social Security Administration to send this payment to the financial institution indicated in Section 3 and deposit it in the designated account. I understand that personal information...
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