information, including suggestions for reducing this burden to OPM Forms Officer, U.S. Office of Personnel Management, Washington, D.C. 20415; The OMB Number, 3206-0001, is currently valid. OPM may not collect this information and you are not required to respond, unless this number …
number. If the number is not known and you cannot obtain it, check the “unknown” box. 13. If the date of birth you show in item 4 is different from the date of birth currently shown on your Social Security record, show the date of birth currently shown on your record in item 13 and provide evidence to support the date of birth shown in item 4.
(Number and Street, City, State and Zip Code) DATE (Month, Day and Year) TELEPHONE NUMBER. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0025.
question number before your answer.) 1. Employment (Give information on your current job or, if you're unemployed, your most recent job.) Form Adopted for Mandatory Use Judicial Council of California FL-150 [Rev. January 1, 2019] INCOME AND EXPENSE DECLARATION. Family Code, §§ 2030–2032, 2100–2113, 3552, 3620–3634, 4050–4076, 4300–4339
Daytime Telephone Number 7. Email Address (if any) Form I-693 07/15/19. Page 6 of 14 I certify under penalty of perjury under United States law that: I am a civil surgeon designated to examine applicants seeking certain immigration benefits in the United States OR a physician who
Number To Give the Requester . for guidelines on whose number to enter. Social security number – – or. Employer identification number – Part II Certification. Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2.
show the name, telephone number, and address of the information contact for the business, the aggregate amount of reportable cash received, and that the information was furnished to the IRS. Keep a copy of the statement for your records. Multiple payments. If you receive more
terminate a reassignment of Medicare benefits after enrollment in the Medicare program or make a change in their reassignment of Medicare benefit information using either: • The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or • The paper CMS-855R application. Be sure you are using the most current version.
Address (Street Number and Name) Apt. Number City or Town State ZIP Code Date of Birth (mm/dd/yyyy) U.S. Social Security Number - - Employee's E-mail Address Employee's Telephone Number I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
VA Form 10-10EZR is used by VA to update your personal, insurance, or financial information after you are enrolled. Please Read Before You Start . . . What is VA Form 10-10EZR used for? SERVICE-CONNECTED (SC): A VA determination that an illness or injury was incurred or aggravated in the line of duty, in the active military, naval or air service.
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