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VA Form 214192 Request for Employment Information in Connection with
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Social security number (first, middle initial, last) 5. Appointment of individual as claimant's representative if you want to have an individual help you with your claim or benefits, have that person complete and submit this form. Return to yes no (if yes, complete items 15b and 15c) $ month day year month day year month day year month day year month day year. Gross monthly amount of benefit
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