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Reset Print Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren 1. Name of deceased employee (Last, first, middle) 2. Date of Birth (Mo., day, year) U.S. Department

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6. If any supporting documents are required, ensure they are gathered and attached securely to the completed form.
7. Review the entire form once again to confirm that all the required fields have been addressed and that there are no errors or omissions.
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