POMS Reference

NL 00720: Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program

TN 2 (09-11)

FUG031 FUGITIVE FELON DUE PROCESS INFORMATION (S42)

(System Generated)

Caption: Your Benefits

 If none of the above apply, we also may pay  (1)  if you contact us within 12 months from the date of this letter and can show us that:

  • The crime for which the warrant was issued or the probation or parole violation was both nonviolent and not drug related and, if a probation or parole violation is involved, the original crime(s) for which  (2)  paroled or put on probation was both nonviolent and not drug related.

                         And

  •  (3)  neither been convicted of nor pled guilty to another felony crime since the date of the warrant

 And The law enforcement agency that issued the warrant reports that it will not extradite  (4)  for the charges on the warrant or that it will not take action on the warrant for  (5)  arrest.

                          Or

  • The crime for which the warrant was issued or the probation or parole violation was both nonviolent and not drug related and, if probation or parole violation is involved, the original crime(s) for which  (6)  paroled or put on probation was both nonviolent and not drug related.

                         And

  •  (7)  neither been convicted of nor pled guilty to another felony crime since the date of the warrant.

                         And

  • The only existing warrant was issued 10 or more years ago.

                         And

  •  (8)  medical condition impairs  (9)  mental capability to resolve the warrant; or  (10)  incapable of managing  (11)  benefits; or  (12)  legally incompetent; or Social Security has appointed a representative payee to handle  (13)  benefits or  (14)  residing in a long-term care facility, such as a nursing home or mental treatment/care facility.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: Beneficiary's Name

Choice 2: you

Fill-in (2) Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

Fill-in (3) Systems Generated

Choice 1: You have

Choice 2: He has

Choice 3: She has

Fill-in (4) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Fill-in (5) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (6) Systems Generated

Choice 1: you were

Choice 2: he was

Choice 3: she was

Fill-in (7) Systems Generated

Choice 1: You have

Choice 2: He has

Choice 3: She has

Fill-in (8) Systems Generated

Choice 1: Your

Choice 2: His

Choice 3: Her

Fill-in (9) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (10) Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (11) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (12) Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

Fill-in (13) Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (14) Systems Generated

Choice 1: you are

Choice 2: he is

Choice 3: she is

FUG058 BENEFICIARY CANNOT BE PAID – OUTSTANDING ARREST WARRANT (S38)

(System Generated)

Caption: Your Benefits

We cannot pay benefits to  (1)  because  (2)  an outstanding arrest warrant for a  (3)  .

Fill-in values:

Fill-in (1)

Choice 1: Beneficiary's name

Choice 2: him

Choice 3: her

Choice 4: you

Fill-in (2)

Choice 1: he has

Choice 2: she has

Choice 3: you have

Choice 4: you

Fill-in (3)

Choice 1: felony crime

Choice 2: violation of a condition of probation or parole under Federal or State law

FUG059 BENEFITS SUSPENDED – FUGITIVE FELON (S39)

(System Generated)

Caption: Your Benefits

Our records show that the  (1)   (2)   (3)  issued a warrant for  (4)  arrest for a felony crime or a violation of Federal or State probation or parole on  (5)  .

 (6) 

 (7)   (8) 

 (9)   (10) 

 (11)   (12) 

 Social Security cannot provide further information about the warrant.  (13)   (14)   (15) 

Fill-in values:

Fill-in (1)

Choice 1: (Warrant Agency)

Choice 2: (Warrant Agency Address)

Fill-in (2)

Choice 1: (Warrant Agency Address)

Choice 2: Null

Fill-in (3)

Choice 1: Phone: + (Warrant Agency Phone)

Choice 2: Null

Fill-in (4)

Choice 1: Beneficiary's name (possessive))

Choice 2: his

Choice 3: her

Choice 4: your

Fill-in (5)

Choice 1: (Warrant Date)

Fill-in (6)

Choice 1: The warrant information we have is:

Choice 2: Null

Fill-in (7)

Choice 1: Warrant number:

Choice 2: Null

Fill-in (8)

Choice 1: Warrant number:

Choice 2: Null

Fill-in (9)

Choice 1: OCA Number:

Choice 2: Null

Fill-in (10)

Choice 1: OCA Number:

Choice 2: Null

Fill-in (11)

Choice 1: OCA Number:

Choice 2: Null

Fill-in (12)

Choice 1: NCIC Number

Choice 2: Null

Fill-in (13)

Choice 1: Please contact the

Choice 2: Null

Fill-in (14)

Choice 1: Warrant Agency Address

Choice 2: Null

Fill-in (15)

Choice 1: directly

Choice 2: Null

FUG060 FUGITIVE FELON SUSPENDED – NO T2 OVERPAYMENT OR T2 OVERPAYMENT NOT DUE TO FUGITIVE FELON DPOT 73 OR 74(S40)

(System Generated)

Caption: Your Benefits

We will pay  (1)  if you contact us at any time and can show us that any of the following apply:

  • The warrant was issued incorrectly in  (2)  name because someone stole  (3)  identity. To prove this, submit a copy of the police report that  (4)  filed as a victim of identity theft or another official document from the court or the warrant issuing agency stating that the warrant was erroneously issued in  (5)  name.

  •  (6)  found not guilty of the criminal offense. To prove this, submit a copy of the court docket indicating  (7)  found not guilty of the criminal charges or a copy of the court decision showing that  (8)  found not guilty of the criminal charges.

  • The underlying charges relating to the criminal offense were dismissed. To prove this, submit a copy of the court docket indicating charges were dismissed or another official court or law enforcement agency document stating that it dismissed the criminal charges.

  • The warrant for  (9)  arrest for the criminal offense was withdrawn. To prove this, submit a copy of the court docket or another official document from the issuing agency, indicating the warrant in question was withdrawn.

  •  (10)  otherwise cleared of the criminal offense. To prove this, submit a copy of the court docket or other court document indicating  (11)  cleared of the criminal charges.

Fill-in values:

Fill-in (1)

Choice 1: Beneficiary's name

Choice 2: him

Choice 3: her

Choice 4: you

Fill-in (2)

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (3)

Choice 1: his

Choice 2: her

Choice 3: you

Fill-in (4)

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (5)

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (6)

Choice 1: He was

Choice 2: She was

Choice 3: You were

Fill-in (7)

Choice 1: he was

Choice 2: she was

Choice 3: you were

Fill-in (8)

Choice 1: he was

Choice 2: she was

Choice 3: you were

Fill-in (9)

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (10)

Choice 1: He was

Choice 2: She was

Choice 3: You were

Fill-in (11)

Choice 1: he was

Choice 2: she was

Choice 3: you were

FUG061 INITIAL AWARD – BENEFICIARY SUSPENDED FUGITIVE FELON (S41)

(System Generated)

Caption: Your Benefits

If none of the above applies, we also may pay  (1)  benefits if you contact us within 12 months from the date of this letter and can show us that:

  • The crime for which the warrant was issued or the probation or parole violation was both nonviolent and not drug related and, if a probation or parole violation is involved, the original crime(s) for which  (2)  paroled or put on probation was both nonviolent and not drug related.

                        And

  •  (3)  neither been convicted of nor pled guilty to another felony crime since the date of the warrant.

                        And

  • The law enforcement agency that issued the warrant reports that it will not extradite  (4)  for the charges on the warrant or that it will not take action on the warrant for  (5)  arrest.

                         Or

  • The crime for which the warrant was issued is based on or the probation or parole violation was both nonviolent and not drug related and, if a probation or parole violation is involved, the original crime(s) for which  (6)  paroled or put on probation was both nonviolent and not drug related.

                       And

  •  (7)  neither been convicted of nor pled guilty to another felony crime since the date of the warrant.

                        And

  • The only existing warrant was issued 10 or more years ago.

                        And

  •  (8)  medical condition impairs  (9)  mental capability to resolve the warrant; or  (10)  incapable of managing  (11)  benefits; or  (12)  legally incompetent; or Social Security has appointed a representative payee to handle  (13)  benefits or  (14)  residing in a long-term care facility, such as a nursing home or mental treatment/care facility.

Fill-in values:

Fill-in (1)

Choice 1: Beneficiary's name

Choice 2: him

Choice 3: her

Choice 4: you

Fill-in (2)

Choice 1: he was

Choice 2: she was

Choice 3: you were

Fill-in (3)

Choice 1: He has

Choice 2: She has

Choice 3: You have

Fill-in (4)

Choice 1: him

Choice 3: her

Choice 4: you

Fill-in (5)

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (6)

Choice 1: he was

Choice 2: she was

Choice 3: you were

Fill-in (7)

Choice 1: He has

Choice 2: She has

Choice 3: You have

Fill-in (8)

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (9)

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (10)

Choice 1: he is

Choice 2: she is

Choice 3: you are

Fill-in (11)

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (12)

Choice 1: he is

Choice 2: she is

Choice 3: you are

Fill-in (13)

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (14)

Choice 1: he is

Choice 2: she is

Choice 3: you are

FUG063 MANDATORY GOOD CAUSE EXPLANATION – BENEFITS SUSPENDED FUGITIVE FELON – T2 OVERPAYMENT RESULTS (S43)

(System Generated)

Caption: Your Benefits

 (1)  will not be overpaid for the months that  (2)  had an outstanding felony warrant for a crime or a warrant for a probation or parole violation if you contact us at any time and can show us that any of the following apply:

  • The warrant was issued incorrectly in  (3)  name because someone stole  (4)  identity. To prove this, submit a copy of the police report that  (5)  filed as a victim of identity theft or another official document from the court or the warrant issuing agency stating that the warrant was erroneously issued in  (6)  name.

  •  (7)  found not guilty of the criminal offense. To prove this, submit a copy of the court docket indicating  (8)  found not guilty of the criminal charges or a copy of the court decision showing that  (9)  found not guilty of the criminal charges.

  • The underlying charges relating to the criminal offense were dismissed. To prove this, submit a copy of the court docket indicating charges were dismissed or another official court or law enforcement agency document stating that it dismissed the criminal charges.

  • The warrant for  (10)  arrest for the criminal offense was withdrawn. To prove this, submit a copy of the court docket or another official document from the issuing agency, indicating the warrant in question was withdrawn.

  •  (11)  otherwise cleared of the criminal offense. To prove this, submit a copy of the court docket or other court document indicating you were cleared of the criminal charges.

Fill-in values:

Fill-in (1)

Choice 1: Beneficiary's name

Choice 2: You

Fill-in (2)

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (3)

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (4)

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (5)

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (6)

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (7)

Choice 1: He was

Choice 2: She was

Choice 3: You were

Fill-in (8)

Choice 1: he was

Choice 2: she was

Choice 3: you were

Fill-in (9)

Choice 1: he was

Choice 2: she was

Choice 3: you were

Fill-in (10)

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (11)

Choice 1: He was

Choice 2: She was

Choice 3: You were

FUG064 DISCRETIONARY GOOD CAUSE-FUGITIVE FELON SUSPENSION RESULTS IN AN OVERPAYMENT-ADVANCE NOTICE NOT SENT (S44)

(Requested/Generated)

Caption: Your Benefits

If none of the above applies, we also may not consider  (1)  overpaid  (2)  for the month(s) of  (3)   (4)   (5)  if you contact us within 12 months from the date of this notice and can show us that:

• The crime for which the warrant was issued or the probation or parole violation was both nonviolent and not drug related and, if a probation or parole violation is involved, the original crime(s) for which  (6)  paroled or put on probation was both nonviolent and not drug related.

                        And

 (7)  neither been convicted of nor pled guilty to another felony crime since the date of the warrant.

                        And

• The law enforcement agency that issued the warrant reports that it will not extradite  (8)  for the charges on the warrant or that it will not take action on the warrant for  (9)  arrest.

                         Or

• The crime for which the warrant was issued is based on or the probation or parole violation was both nonviolent and not drug related and, if a probation or parole violation is involved, the original crime(s) for which  (10)  paroled or put on probation was both nonviolent and not drug related.

                        And

 (11)  neither been convicted of nor pled guilty to another felony crime since the date of the warrant.

                        And

   • The only existing warrant was issued 10 or more years ago.

                        And

 (12)  medical condition impairs  (13)  mental capability to resolve the warrant; or  (14)  incapable of managing  (15)  benefits; or  (16)  legally incompetent; or Social Security has appointed a representative payee to handle  (17)  benefits or  (18)  residing in a long-term care facility, such as a nursing home or mental treatment/care facility.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's name

Choice 2: you

Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: amount

Fill-in (3) - Requested As A Date In Format Shown Below

Date MM/CCYY

Fill-in (4) - Requested As A One Position Alpha Character

Choice 1: (A) and

Choice 2: (B) through

Choice 3: (C) null

Fill-in (5) - Requested As A Date In Format Shown Below or As A One Position Alpha Character

Choice 1: Date MM/CCYY

Choice 2: (B) null

Fill-in (6) - Systems Generated

Choice 1: he was

Choice 2: she was

Choice 3: you were

Fill-in (7) - Systems Generated

Choice 1: He has

Choice 2: She has

Choice 3: You have

Fill-in (8) - Systems Generated

Choice 1: him

Choice 2: her

Choice 3: you

Fill-in (9) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (10) - Systems Generated

Choice 1: he was

Choice 2: she was

Choice 3: you were

Fill-in (11) - Systems Generated

Choice 1: He has

Choice 2: She has

Choice 3: You have

Fill-in (12) - Systems Generated

Choice 1: His

Choice 2: Her

Choice 3: Your

Fill-in (13) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (14) - Systems Generated

Choice 1: he is

Choice 2: she is

Choice 3: you are

Fill-in (15) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (16) - Systems Generated

Choice 1: he is

Choice 2: she is

Choice 3: you are

Fill-in (17) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (18) - Systems Generated

Choice 1: he is

Choice 2: she is

Choice 3: you are

FUG065 DISCRETIONARY GOOD CAUSE – FUGITIVE FELON SUSPENSION RESULTS IN AN OVERPAYMENT –ADVANCE NOTICE SENT (S45)

(Requested/Generated)

Caption: Your Benefits

If none of the above applies, we also may not consider  (1)  overpaid  (2)  for the month(s) of  (3)   (4)   (5)  if you contact us within 12 months from  (6)  and can show us that:

• The crime for which the warrant was issued or the probation or parole violation was both nonviolent and not drug related and, if a probation or parole violation is involved, the original crime(s) for which  (7)  paroled or put on probation was both nonviolent and not drug related.

                        And

 (8)  neither been convicted of nor pled guilty to another felony crime since the date of the warrant.

                        And

• The law enforcement agency that issued the warrant reports that it will not extradite  (9)  for the charges on the warrant or that it will not take action on the warrant for  (10)  arrest.

                         Or

• The crime for which the warrant was issued is based on or the probation or parole violation was both nonviolent and not drug related and, if a probation or parole violation is involved, the original crime(s) for which  (11)  paroled or put on probation was both nonviolent and not drug related.

                        And

 (12)  neither been convicted of nor pled guilty to another felony crime since the date of the warrant.

                       And

   • The only existing warrant was issued 10 or more years ago.

                        And

 (13)  medical condition impairs  (14)  mental capability to resolve the warrant; or  (15)  incapable of managing  (16)  benefits; or  (17)  legally incompetent; or Social Security has appointed a representative payee to handle  (18)  benefits or  (19)  residing in a long-term care facility, such as a nursing home or mental treatment/care facility.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's name

Choice 2: you

Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢

Amount

Fill-in (3) - Requested As A Date In Format Shown Below

Date MM/CCYY

Fill-in (4) - Requested As A One Position Alpha Character

Choice 1: (A) and

Choice 2: (B) through

Choice 3: (C) null

Fill-in (5) - Requested As A Date In Format Shown Below or As A One Position Alpha Character

Choice 1: Date MM/CCYY

Choice 2: (B) null

Fill-in (6) - Requested As A Date In Format Shown Below

Date MM/DD/CCYY

Fill-in (7) - Systems Generated

Choice 1: he was

Choice 2: she was

Choice 3: you were

Fill-in (8) - Systems Generated

Choice 1: He has

Choice 2: She has

Choice 3: You have

Fill-in (9) - Systems Generated

Choice 1: him

Choice 2: her

Choice 3: you

Fill-in (10) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (11) - Systems Generated

Choice 1: he was

Choice 2: she was

Choice 3: you were

Fill-in (12) - Systems Generated

Choice 1: He has

Choice 2: She has

Choice 3: You have

Fill-in (13) - Systems Generated

Choice 1: His

Choice 2: Her

Choice 3: Your

Fill-in (14) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (15) - Systems Generated

Choice 1: he is

Choice 2: she is

Choice 3: you are

Fill-in (16) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (17) - Systems Generated

Choice 1: he is

Choice 2: she is

Choice 3: you are

Fill-in (18) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

Fill-in (19)

Choice 1: he is

Choice 2: she is

Choice 3: you are

FUG104 MARTINEZ RESUMPTION (S47)

(System Generated)

Caption: Information About The Martinez Settlement

We have reviewed  (1)  claim because of the settlement of the Martinez court case. This settlement changes the types of arrest warrants that we can use to affect the payment of benefits. Our records show that  (2)  an outstanding arrest warrant that we will no longer use to affect the payment of  (3)  benefits.

Fill-in values:

Fill-in (1)

Choice 1: Name possessive

Choice 2: your

Fill-in (2)

Choice 1: Name has

Choice 2: you have

Fill-in (3)

Choice 1: his

Choice 2: her

Choice 3: your

FUG105 MARTINEZ RESUMPTION BENEFICIARY EFFECTIVE 4/1/09 OR LATER (S48)

(System Generated)

Caption: Information About The Martinez Settlement

We have reviewed  (1)  claim because of the settlement of the Martinez court case. Starting April 1, 2009, this settlement changes the types of arrest warrants that we can use to affect the payment of benefits. Our records show that  (2)  an outstanding arrest warrant that we will no longer use to affect the payment of  (3)  benefits.

Fill-in values:

Fill-in (1)

Choice 1: Name possessive

Choice 2: your

Fill-in (2)

Choice 1: Name has

Choice 2: you have

Fill-in (3)

Choice 1: his

Choice 2: her

Choice 3: your

FUG106 MARTINEZ SETTLEMENT OVERPAYMENT CANCELLATION OR REDUCTION (S49)

(System Generated)

Caption: Information About The Martinez Settlement

 (1)   (2)  overpayment on our records because of the settlement of the Martinez court case. This settlement changes the types of arrest warrants that we can use to affect the payment of benefits.

Fill-in values:

Fill-in (1)

Choice 1: We removed

Choice 2: We reduced

Fill-in (2)

Choice 1: your

Choice 2: Name possessive

FUG114 MARTINEZ DENAIL

(Requested)

Caption: Information About The Martinez Settlement

We have looked at the earlier decision we made on  (1)  case to see if the Martinez Settlement affects that decision. We found that this court settlement does not change our earlier decision. We cannot  (2)   (3)   (4)  for the fugitive suspension period, because we cannot disregard  (5)  type of unsatisfied  (6)  .

Our earlier decision remains the final decision of the agency in  (7)  case.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Beneficiary's name

Choice 2: your

Fill-in (2) - Requested As A One Position Alpha Character

Choice 1: (A) reinstate

Choice 2: (B) resume

Choice 3: (C) cancel

Choice 4: (D) reduce

Fill-in (3) - Systems Generated

Choice 1: Beneficiary's name

Choice 2: your

Fill-in (4) - Requested As A One Position Alpha Character

Choice 1: (A) payment

Choice 2: (B) overpayment

Fill-in (5) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Choice 4: Beneficiary's name Possessive

Fill-in (6) - Requested As A One Position Alpha Character

Choice 1: (A) parole violation warrant

Choice 2: (B) probation violation warrant

Choice 3: (C) felony warrant

Fill-in (7) - Systems Generated

Choice 1: Beneficiary's name

Choice 2: your

FUG118 CLARK V. ASTRUE COURT CASE- OUTSTANDING WARRANT WILL NO LONGER AFFECT BENEFITS

(Requested)

Caption: Information About the Clark Court Case

We have reviewed  (1)  benefits because of the Clark v. Astrue court case. This case changes the types of warrants that we can use to affect the payment of benefits. Our records show that  (2)  an outstanding warrant that we will no longer use to affect the payment of  (3)  benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary’s Name (Possessive)

Fill-in (2) - Systems Generated

Choice 1: you have

Choice 2: Beneficiary’s Name has

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 2: her

FUG121 REDUCING OR CANCELING AN OVERPAYMENT BECAUSE OF CLARK COURT CASE

(Requested)

Caption: Information About the Clark Court Case

 (1)  an overpayment  (2)   (3)  record because of the Clark v. Astrue court case. This case changes the types of warrants that we can use to affect the payment of  (4)  benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: We removed

Choice 2: We reduced

Fill-in (2) - Systems Generated

Choice 1: from

Choice 2: on

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: Beneficiary’s Name (Possessive)

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 2: her

FUG122 NO RELIEF IS DUE TO THE BENEFICARY BECAUSE OF CLARK V. ASTRUE

(Requested)

Caption: Information About the Clark Court Case

We also looked at the earlier decision we made on  (1)  case to see if the Clark v. Astrue court case could change that decision. We found that this court case does not affect our earlier decision. No other relief is due  (2)  because of Clark for months that we did not pay  (3)  because of an outstanding warrant. Our earlier decision remains the final decision of the agency in  (4)  case.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: Beneficiary’s Name (Possessive)

Fill-in (2) - Systems Generated

Choice 1: you

Choice 2: Beneficiary’s Name

Fill-in (3) - Systems Generated

Choice 1: you

Choice 2: him

Choice 2: her

Fill-in (4) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her