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1 . U N I T I . D .
6 6 7 5 3 S H I P O R S T A T I O N
N R O T C U N I T , J A C K S O N V I L L E U N I V E R S I T Y 3 . 4 . 5 . N A M E O F S P O U S E
F O R M T E X T 6 . D A T E O F B I R T H O F S P O U S E
F O R M T E X T 7 . R E L A T I O N S H I P
F O R M T E X T 8 . P L A C E O F M A R R I A G E ( C I T Y & S T A T E O R C O U N T R Y )
F O R M T E X T D A T E M A R R I E D
F O R M T E X T 1 0 . C I T I Z E N S H I P O F S P O U S E
F O R M T E X T 1 1 . A D D R E S S O F S P O U S E
F O R M T E X T 1 2 . D E P
F O R M T E X T 1 3 . N A M E O F C H I L D O R D E P E N D E N T
1 4 . D A T E O F B I R T H
1 5 . R E L A T I O N S H I P
F O R M T E X T 1 6 . A D D R E S S ( I N C L U D E N A M E O F C U S T O D I A N I F O T H E R T H A N C L A I M A N T )
1 7 . D E P
1 8 . N A M E O R C H I L D O R D E P E N D E N T
F O R M T E X T D A T E O F B I R T H
F O R M T E X T 2 0 . R E L A T I O N S H I P
F O R M T E X T 2 1 . A D D R E S S ( I N C L U D E N A M E O F C U S T O D I A N I F O T H E R T H A N C L A I M A N T )
F O R M T E X T 2 2 . D E P
F O R M T E X T 2 3 . N A M E O R C H I L D O R D E P E N D E N T
F O R M T E X T 2 4 . D A T E O F B I R T H
F O R M T E X T 2 5 . R E L A T I O N S H I P
F O R M T E X T 2 6 . A D D R E S S ( I N C L U D E N A M E O F C U S T O D I A N I F O T H E R T H A N C L A I M A N T )
F O R M T E X T 2 7 . D E P
F O R M T E X T 2 8 . N A M E O R C H I L D O R D E P E N D E N T
F O R M T E X T 2 9 . D A T E O F B I R T H
F O R M T E X T 3 0 . R E L A T I O N S H I P
F O R M T E X T 3 1 . A D D R E S S ( I N C L U D E N A M E O F C U S T O D I A N I F O T H E R T H A N C L A I M A N T )
F O R M T E X T 3 2 . D E P
3 3 . N A M E O F F A T H E R
3 4 . A D D R E S S O F F A T H E R ( S E E S P E C I A L I N S T R U C T I O N S B E F O R E C O M P L E T I N G B L O C K 3 5 )
3 5 . D E P
N O 3 6 . N A M E O F M O T H E R
3 7 . A D D R E S S O F M O T H E R ( S E E S P E C I A L I N S T R U C T I O N S B E F O R E COMPLETING BLOCK 38)
38. DEP
NO39. WERE YOU PREVIOUSLY
MARRIED? FORMCHECKBOX YES FORMCHECKBOX NO40. PRIOR MARRIAGE DISSOLVED BY
FORMCHECKBOX DEATH FORMCHECKBOX ANNULMENT FORMCHECKBOX DIVORCE41. DATE
42. PLACE (CITY & STATE OR COUNTRY)
43. WAS SPOUSE PREVIOUSLY
MARRIED? FORMCHECKBOX YES FORMCHECKBOX NO44. PRIOR MARRIAGE DISSOLVED BY
FORMCHECKBOX DEATH FORMCHECKBOX ANNULMENT FORMCHECKBOX DIVORCE45. DATE
FORMTEXT 4 6 . P L A C E ( C I T Y & S T A T E O R C O U N T R Y )
F O R M T E X T 4 7 . O T H E R
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F O R M T E X T 5 3 . B E N E F I C I A R Y ( S ) F O R U N P A I D P A Y A N D A L L O W A N C E S
5 4 . A D D R E S S
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F O R M T E X T 6 5 A D D R E S S
F O R M T E X T P O L I C Y N U M B E R
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7 8 . R E M A R K S
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7 9 . S I G N A T U R E O F D E S I G N A T O R
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