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Form approved: OMB number: 32060174 Survivor Annuity Election for a Spouse Your full name (Please print) Your claim number CSA Please Provide the Following Information About Your Spouse's full name
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OMB number 3206-0174 2010 1943 Washington RI CSA OPM identifier terminates authorizes electing eligibility Annuity computing continuation usable Revoke pamphlets solicitation verification Specify Publications accompanying editions furnish reducing Revised elect displayed

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