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Input Date Waiver Approval Denial Please answer the questions on this form as completely as you can* We will help you fill out the form if you want. If you are filling out this form for someone else answer the questions as they apply to that person* SSI AMT OF OP PERIOD DATES OF OP A. Name of person on whose record the overpayment occurred B. Social Security Number C. Name of overpaid person s making this request and his/her Social Security Number s Check any of the following that apply. Also f ...

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