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Participant claim form

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If you have any questions call 1-800-729-7327 or visit our website at www. justice. gov/civil/common/reca*html* No individual may receive more than one payment under the Act. Sec* 7 b. Part 1 YOU the person filling out this form* First name Middle name Last name Maiden name if applicable Other names Former names Social Security number - Date of Birth mm/dd/yy Mailing address City State Phone number day Zip Code Phone number evening Residence address If you are a member of an Indian Tribe please ...

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