may be affected by information that
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Your explanation of this information will determine whether or not you are entitled to benefits. Future claims you file may also be affected. You may call collect
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and ask for
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If this is not convenient, please either fax to (Blank line _______________ ) or mail (to the field office address listed below) the information requested below along with any other document or information you want us to consider.
Ten days after the above mail date, a decision will be made based on all information in our possession.
Claims Interviewer
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Field Office Address