Application for Widow's or Widower's Insurance Benefits--Modernized Claims System (MCS)

MCS

RSDHI CLAIMS APPLICATION

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1	C	MCS TRANSFER TO: XXXX RSDHI CLAIMS APPLICATION APPL SC0	5
2	0
3	l	NH NAME: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
4	u	SSN: SSSSSSSSS SEX: X BIRTHDATE: 99999999
5	m	PROOF (A/B/C/F/Q): X PROOF TYPE (P/H/N/O): X
6	n	SELECT CLAIM TYPE(S): 9 9 9 1. RETIREMENT 4. AUXILIARY 7. AGE 72
7	*	2. DISABILITY 5. UNINS MED ONLY 8. ESRD
8	o	ABBREVIATED APPLICATION: X 3. SURVIVOR 6. LUMP SUM
9	n	FILING FOR SELF ONLY
10	e	CLAIMANT (IF DIFFERENT)
11		NAME: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
12	r	SSN: 999999999 SEX: X BIRTHDATE: 99999999
13	e	PROOF (A/B/C/F/Q): X PROOF TYPE (P/H/N/O): X
14	s	RELATIONSHIP TO NH: 9 1. SPOUSE (SUBSEQUENT CLAIM: X) 1. RIB
15	e	2. SPOUSE WITH CHILD IN CARE 2. DIB
16	r	3. CHILD
17	v	APPLICANT (IF DIFFERENT) 4. DEPENDENT PARENT
18	e	NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
19	d	SSN: 999999999 EIN: 999999999 WILL APPLICANT BE ENTERED IN RPS (Y/N): X
20		SELECT TYPE OF CHANGE: 9 1. NH NAME 4. CLAIM TYPE
21		2. CL NAME 5. RELATIONSHIP TYPE
22		3. APPLICANT NAME 6. SUBSEQUENT CLAIM INDICATOR
23		**************(line 23 reserved for applications information)*****************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

CLAIM CONTACT METHOD DATA

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1	C	MCS CLAIM CONTACT METHOD DATA CCMD SC9	5
2	0	NH: SSSSSSSSS SSSSS SSSSSSSSSS CL: SSSSSSSSS SSSSS SSSSSSSSSS
3	l	SELECT CONTACT METHOD FOR ESTABLISHING APPLICATION
4	u	*CLAIM TYPE: SSSSSS CONTACT METHOD 1: 99
5	m	CLAIM TYPE: SSSSSS CONTACT METHOD 2: 99
6	n	CLAIM TYPE: SSSSSS CONTACT METHOD 3: 99
7	*	1=TELEPHONE –CLAIM INITIATED OVER THE PHONE, USUALLY BY APPOINTMENT
8	o	2=VISIT -CLAIM INITIATED IN PERSON WITH THE CLAIMANT
9	n	3=MAIL -RECEIVED PAPER APPLICATION IN THE MAIL AND LOADED IN MCS
10	e	4=INTERNET -CLAIM STARTED AND COMPLETED ON THE INTERNET
11		5=ICT -CLAIM ORIGINATED THROUGH 800 NUMBER CALL AND REFERRED TO ICT UNIT
12	r	6=OTHER -NO OTHER CM VALUE IS CURRENTLY APPROPRIATE.
13	e
14	s
15	e	UNSATISFIED FELONY WARRANTS FOR YOUR ARREST? (Y/N) A
16	r	UNSATISFIED FEDERAL/STATE WARRANTS FOR VIOLATION OF PROBATION/PAROLE? (Y/N): A
17	v	DO YOU WANT TO CHECK THE STATUS OF YOUR CLAIM USING THE INTERNET? (Y/N): A
18	e	IF AWARDED, DO YOU WANT A PASSWORD TO USE SSA INTERNET/PHONE SERVICE? (Y/N): A
19	d
20		SELECT MAILING METHOD (BLIND NOTICE INFORMATION) TYPE: 9
21		1=CERTIFIED MAIL 2=TELEPHONE CONTACT 3=REGUALR MAIL.
22		PF1 FOR HELP TRANSFER TO: XXXX
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24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

IDENTIFICATION

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1	C	MCS IDENTIFICATION IDEN SC0	8
2	0	NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
3	l	LANGUAGE SPOKEN AND WRITTEN IS ENGLISH (Y/N): X
4	u	BIRTH CITY: XXXXXXXXXXXXXXX BIRTH STATE: XX BIRTH COUNTRY: XX
5	m	RECORD OF BIRTH BEFORE AGE 5 PUBLIC (Y/N): X RELIGIOUS (Y/N): X
6	n	OTHER NAMES USED: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
7	*	XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
8	o	XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
9	n	XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
10	e	XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
11		EVER MARRIED (Y/N): P CURRENTLY MARRIED (Y/N): X
12	r	*CHILD UNDER 18, STUDENT 18 TO 19, 18 OR OLDER AND DISABLED BEFORE 22 (Y/N): X
13	e	WORK OR EARNINGS IN SSSS SSSS SSSS SSSS (Y/N): X
14	s
15	e	DISABLED IN LAST 14 MONTHS (Y/N): X ONSET DATE: 99999999
16	r	IF YES, APPLYING FOR DISABILITY ON THIS ACCOUNT (Y/N): X
17	v	*SELECT FILED OR INTEND TO FILE FOR SSI: 9
18	e	1=YES
19	d	2=NOT DISABLED, BLIND OR WITHIN W MONTHS OF AGE 65 OR OLDER
20		3=DOES NOT WISH TO FILE.
21
22		TRANSFER TO: XXXX
23		**************(line 23 reserved for applications information)*****************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

IDENTIFICATION SCREEN 2

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1	C	MCS IDENTIFICATION IDN2 SC1	1
2	0	NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
3	l
4	u	PRIOR APPLICATION FOR RSDI (Y/N): X FOR SSI (Y/N): X FOR MEDICARE (Y/N): X
5	m	CROSS REFERENCE SSN: 9999999999 STAT: XX SSN: 999999999 STAT: XX
6	n	[~NH NAME IN PRIOR APPLICATION
7	*	[ FIRST NAME MI LAST NAME SSN
8	o	| XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX XXXXXXXXX
9	n	| XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX XXXXXXXXX
10	e	MULTIPLE SSN: 999999999 999999999 999999999 999999999 999999999
11
12	r
13	e
14	s
15	e
16	r
17	v
18	e
19	d
20
21
22		TRANSFER TO: XXXX
23		**************(line 23 reserved for applications information)*****************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

ADDITIONAL BENEFITS

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1	C	MCS TRANSFER TO: ADDITIONAL BENEFITS ADDB SC1	0
2	0	NH SSSSSSSSS SSSSS SSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSS
3	l	ACTIVE U.S. MILITARY/RESERVE/NATL GUARD SERVICE AFTER SEPT 7 1939 (Y/N): N
4	u	WORKED IN RR FOR 5 YEARS OR MORE (Y/N): N SPOUSE (Y/N): N
5	m	RECEIVING RR RETIREMENT PENSION/ANNUITY (Y/N): N SPOUSE (Y/N): N
6	n	COVERED UNDER FOREIGN SSA (Y/N): N COUNTRY: IF COVERED,
7	*	FILING FOR FOREIGN SSA (Y/N): REQ FOREIGN QC’S FOR U.S. FILING (Y/N):
8	o	SPOUSE COVERED UNDER SSA OF OTHER COUNTRY (Y/N): COUNTRY:
9	n	CIVILIAN EMPLOYEE OF FEDERAL GOVT IN JAN 1983 (Y/N): N SPOUSE (Y/N): N
10	e	JAPANESE INTERNEE (Y/N): N VOW OF POVERTY (Y/N): N
11
12	r	QUALITY FOR US FED/STATE/LOCAL GOVT PENSION BASED ON OWN WORK (Y/N): X
13	e
14	s	CURRENTLY ENTITLED TO A PENSION NOT COVERED UNDER SSA (Y/N): X
15	e	IF NO, DO YOU EXPECT TO BE ENTITLED TO A PENSION NOT COVERED UNDER SSA
16	r	IN THE FUTURE (Y/N): X IF YES, SHOW FUTURE ENTITLEMENT DATE (MMYY): 9999
17	v
18	e	FILING FOR MEDICARE ONLY, RESTRICTING MONTHLY BENEFITS (Y/N): N
19	d	WILL MEDICARE APPLY: 2 1. YES 2. NO 3. ALREADY ENROLLED ON ANOTHER SSN
20
21		IF CLAIMANT IS FILING AS A SURVIVING SPOUSE, IS CLAIMANT
22		FILING FOR BENEFITS ON OWN RECORD (Y/N):
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24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

NH IDENTIFICATION

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1	C	MCS NH IDENTIFICATION NHID SC0	6
2	0	NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
3	l
4	u	EVER MARRIED (Y/N): X
5	m	CHILD UNDER 18, STUDENT 18 TO 19, 18 OR OLDER AND DISABLED BEFORE 22 (Y/N): X
6	n	NH DEP PARENTS (Y/N): X
7	*
8	o	WORK LAST YEAR OR THIS YEAR (Y/N): X
9	n	PRIOR APPLICATION FOR RSDI (Y/N): X FOR SSI (Y/N): X FOR MEDICARE (Y/N): X
10	e	CROSS REFERENCE SSN: 999999999 STAT: XX SSN: 999999999 STAT: XX
11		NH NAME IN PRIOR APPLICATION: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX SSN: 999999999
12	r	NH NAME IN PRIOR APPLICATION: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX SSN: 999999999
13	e
14	s	MULTIPLE SSN: 999999999 999999999 999999999 999999999 999999999
15	e	OTHER NAMES: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
16	r	XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
17	v	XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
18	e	XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
19	d	XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
20
21
22		TRANSFER TO: XXXX
23		**************(line 23 reserved for applications information)*****************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

INFORMATION ABOUT THE DECEASED

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1	C	MCS TRANSFER TO: XXXX INFORMATION ABOUT THE DECEASED DECD SC0	7
2	0	NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
3	l
4	u	DATE OF DEATH: 999999999 PROOF (P/N): X TYPE OF PROOF (P/O): X
5	m	DOMICILE AT DEATH: XXXXXXXXXXXXXXX
6	n	PLACE OF DEATH (CITY/STATE): XXXXXXXXXXXXXXX
7	*
8	o	DISABLED AT TIME OF DEATH (Y/N): X DISABILITY BEGAN: 999999
9	n	WAS CLAIMANT ELIGIBLE AS WIDOW(ER) PRIOR TO 1985 ON ANY SSN (Y/N): X
10	e	SURVIVING SPOUSE (Y/N): X
11		NAME: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
12	r	ADDRESS: XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
13	e	XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
14	s	SPOUSE LIVING WITH DECEASED AT TIME OF DEATH (Y/N): X
15	e	AWAY FROM HOME: 9 1. DECESED DATE LAST HOME: 999999
16	r	2. SPOUSE
17	v	REASON FOR SEPARATION AT DEATH: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
18	e	IF DUE TO ILLNESS, NATURE OF ILLNESS: XXXXXXXXXXXXXXXXXXXXXXXXXXX
19	d	REASON ABSENCE BEGAN: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
20		IS SPOUSE: 9 1. LIVING IN SAME HOUSEHOLD 2. ELIGIBLE OR ENTITLED TO BEN	S
21		3. NOT ENTITLED TO LSDP
22
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24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

NH ADDITIONAL BENEFITS

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1	C	MCS TRANSFER TO: XXXX NH ADDITIONAL BENEFITS NHAB SC3	2
2	0	NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
3	l
4	u	ACTIVE U.S. MILITARY/RESERVE/NATL GUARD SERVICE AFTER SEPT 7 1939 (Y/N): X
5	m	WORKED IN RR FOR 5 YEARS OR MORE (Y/N): X
6	n	RECEIVING RR RETIREMENT PENSION/ANNUITY (Y/N): X
7	*	COVERED UNDER FOREIGN SSA (Y/N): X COUNTRY: XXXXXXXXXX IF COVERED,
8	o	FILING FOR FOREIGN SSA (Y/N): X REQUIRES FOREIGN QC’S FOR US FILING (Y/N):	X
9	n	CIVILIAN EMPLOYEE OF FEDERAL GOVT IN JAN 1983 (Y/N): X
10	e	JAPANESE INTERNEE: (Y/N): X VOW OF POVERTY (Y/N): X
11
12	r
13	e
14	s
15	e
16	r
17	v
18	e
19	d
20
21
22
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24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

NH MARRIAGE

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1	C	MCS NH MARRIAGE NMAR SC4	3
2	0	NH: SSSSSSSSS SSSSS SSSSSSSSSS CL: SSSSSSSSS SSSSS SSSSSSSSSS
3	l	*SPOUSE’S FIRST NAME: XXXXXXXXXXXXXXX MI: X *LAST NAME: XXXXXXXXXXXXXXXXXXXX
4	u	SPOUSE’S SSN: 9999999999
5	m	SPOUSE’S BIRTHDATE (MMDDCCYY): 99999999 IF BIRTHDATE UNKNOWN, AGE: 999
6	n	*MARRIAGE DATE (MMDDCCYY): 99999999 *PROOF (Y/N): A
7	*	MARRIAGE CITY: XXXXXXXXXXXXXXX MARRIAGE STATE/FOREIGN COUNTRY: XX
8	o	SELECT MARRIAGE TYPE: 9 1=CLERGY/PUBLIC OFFICIAL
9	n	2=COMMON LAW
10	e	3=OTHER CEREMONIAL
11		4=DEEMED.
12	r	*MARRIAGE ENDED(Y/N): X MARRIAGE END DATE (MMDDCCYY): 99999999 PROOF (Y/N): A
13	e	MARRIAGE ENDED CITY: XXXXXXXXXXXXXXX MARRIAGE ENDED STATE/FOREIGN COUNTRY: XX
14	s	SELECT REASON: 9 1=DEATH
15	e	2=DIVORCE
16	r	3=ANNULMENT OF VOIDABLE
17	v	4=PUTATIVE
18	e	5=VOID/VOIDED.
19	d
20		IF SPOUSE DECEASED, DATE OF DEATH (MMDDCCYY): 99999999
21		*OTHER MARRIAGES: (Y/N): A DELETE SCREEN: (Y/N): A
22		PAGE: 9 TRANSFER TO: XXXX
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24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

WORK HISTORY

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1	C	MCS TRANSFER TO: XXX WORK HISTORY WORK SC1	6
2	0	NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
3	l
4	u	EMPLOYED IN SSSS SSSS SSSS SSSS (Y/N): X MMYY MMYY
5	m	EMPLOYER NAME & ADDRESS START DATE END DATE N/E
6	n	1. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
7	*	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 9999 9999 X
8	o	2. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
9	n	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 9999 9999 X
10	e	3. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
11		XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 9999 9999 X
12	r	AUTHORIZATION TO CONTACT EMPLOYERS (Y/N): X
13	e	CORPORATE OFFICER (Y/N): X RELATED TO CORPORATE OFFICER (Y/N): X
14	s	CLOSE/FAMILY CORPORATION (Y/N): X
15	e	SELF-EMPLOYED IN SSSS SSSS SSSS SSSS (Y/N): X
16	r	IF YES, SHOW: YEARS TYPE OF BUSINESS NET OVER $400(Y/N)
17	v	99 XXXXXXXXXXXXXXXXXXXXXXXXXXX X
18	e	99 XXXXXXXXXXXXXXXXXXXXXXXXXXX X
19	d	99 XXXXXXXXXXXXXXXXXXXXXXXXXXX X
20		99 XXXXXXXXXXXXXXXXXXXXXXXXXXX X
21
22		MORE (Y/N): X DELETE THIS PAGE (Y/N): X PAGE: S
23		**************(line 23 reserved for applications information)*****************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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EARNINGS

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1	C	MCS TRANSFER TO: EARNINGS EARN
2	0	NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
3	l
4	u	LIST ALL EARNINGS AND TYPES FOR 2001 2002 2003
5	m	TYPES ARE: 1=FICA WAGES 2=SEI 3=EMPLOYEE REPORTIED TIPS 4=RR LAG
6	n	PROOF CODES ARE: P=PROVEN R=READILY AVAILABLE N=NOT AVAILABLE D=DELETED LAG
7	*	YEAR TYPE AMOUNT PRF
8	o	99 9 99999.99 A
9	n	99 9 99999.99 A
10	e	99 9 99999.99 A
11		99 9 99999.99 A
12	r	99 9 99999.99 A
13	e	99 9 99999.99 A
14	s	99 9 99999.99 A
15	e	99 9 99999.99 A
16	r	99 9 99999.99 A
17	v	99 9 99999.99 A
18	e	99 9 99999.99 A
19	d	99 9 99999.99 A
20		DO YOU WISH US TO COMPUTE YOUR BENEFITS AND COMPLETE YOUR CLAIM WITHOUT USING
21		UNPOSTED RECENT EARNINGS (Y/N):
22
23		**************(line 23 reserved for applications information)*****************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

NH MILITARY SERVICE

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1	C	MCS NH MILITARY SERVICE NHMS SC4	5
2	0	NH: SSSSSSSSS SSSSS SSSSSSSSSS CL: SSSSSSSSS SSSSS SSSSSSSSSS
3	l	FIRST NAME USED IN SERVICE: XXXXXXXXXX MI: X LAST NAME: SSSSSSSSSSSSSSSSSSS
4	u	SERVICE NO: XXXXXXXXX
5	m	*RECEIVE OR ELIGIBLE FOR MIL OR CIV FEDERAL AGENCY BENEFIT (SELECT ONE): 9
6	n	1=CIVILIAN 2=MILITARY 3=BOTH 4=NONE.
7	*	[ A/R BRANCH OF SERVICE START END N/E RANK PROOF
8	o	| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
9	n	| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
10	e	| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
11		| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
12	r	| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
13	e	| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
14	s	| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
15	e	| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
16	r	| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
17	v	| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
18	e	IS DEVELOPMENT OF VA SURVIVOR PENSION REQUIRED (Y/N): X
19	d	[JAPANESE INTERNEE START END PROOF HOURLY WAGE
20		| 999999 999999 X 99999999
21		| 999999 999999 X 99999999
22		PF1 FOR HELP MORE (Y/N): X PAGE: 1 TRANSFER TO: XXXX
23		**************(line 23 reserved for applications information)*****************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

NH MILITARY RETIREMENT/FEDERAL BENEFIT

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1	C	MCS TRANSFER TO: XXXX NH MILITARY RETIREMENT/FEDERAL BENEFIT NHMR SC4	6
2	0	NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
3	l
4	u	IF RETIRED FROM MILITARY, BASIS OF RETIREMENT: 9
5	m	1. LENGTH OF SERVICE 3. RESERVE SERVICE PAYABLE AT AGE 60
6	n	2. DISABILITY 4. OTHER
7	*	IF OPTION 4 CHOSEN, EXPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXX
8	o	IF RETIRED AND SERVICE AFTER DEC 31, 1956, INDICATE BRANCH OF SERVICE PAYING
9	n	BENEFIT: 9 1. ARMY 5. COAST GUARD
10	e	2. NAVY 6. PUBLIC HEALTH SERVICE
11		3. AIR FORCE 7. COASTAL/GEODETIC SURVEY
12	r	4. MARINE CORPS 8. OTHER
13	e	IF OPTION 8 CHOSEN, EXPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXX
14	s	WAIVED ALL/PART OF RETIREMENT TO GET VA OR OTHER FED CREDIT (Y/N): X
15	e
16	r	IF ELIGIBLE FOR CIVILIAN FEDERAL AGENCY BENEFITS, INDICATE BENEFIT TYPE: 9
17	v	1. SERVICE 2. SURVIVOR 3. DISABILITY 4. OTHER
18	e	IF OPTION 4 CHOSEN, EXPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXX
19	d	NAME OF FED AGENCY: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
20		YEARS EMPLOYED: 99 DATE CLAIM FILED: 999999 CLAIM NO.: XXXXXXXXXXXX
21		MOST RECENT AGENCY: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
22		CITY: XXXXXXXXXXXXX STATE: XX LAST WORKED: 999999
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24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

WORK DEDUCTIONS/ELECTION OPTION

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1	C	MCS TRANSFER TO: XXXX WORK DEDUCTIONS/ELECTION OPTION DEME SC3	4
2	0	NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
3	l
4	u	LIST TYPES, AMOUNTS, PRFS, AND NON-SERVICE MONTHS FOR SSSS SSSS SSSS
5	m	TYPES ARE: 1=WAGES 2=SEI 3=WAGES AND SEI PRF: P-PERM
6	n	NON-SERVICE MONTHS PLACE AN X UNDER ALL, NONE, OR EACH MONTH THAT APPLIES
7	*	YEAR TYPE AMOUNT ALL NONE 01 02 03 04 05 06 07 08 09 10 11 12 PRF FY END	S
8	o	SS X XXXXXXXXX X X X X X X X X X X X X X X X 99
9	n	SS X XXXXXXXXX X X X X X X X X X X X X X X X 99
10	e	SS X XXXXXXXXX X X X X X X X X X X X X X X X 99
11		IF OVER THE MAX OR NONCOVERED EARNINGS INVOLVED, CORRECT THE ABOVE AMOUNTS.
12	r	SPECIAL PAYMENTS INVOLVED (Y/N): X IF YES, CORRECT ABOVE
13	e	FOREIGN WORK SERVICE MONTHS
14	s	(YY) ALL 01 02 03 04 05 06 07 08 09 10 11 12
15	e	99 X X X X X X X X X X X X X
16	r	99 X X X X X X X X X X X X X
17	v	99 X X X X X X X X X X X X X
18	e	ELECTION/ENTITLEMENT OPTION: X DATE(MMYY): 9999
19	d	A. MOST ADVANTAGEOUS MONTH B. EARLIEST MONTH WITHOUT REDUCTION
20		C. CLAIMANT’S CHOSEN MONTH D. UNREDUCED CLAIMANT
21		E. NOT APPLICABLE (DIB AUX SPOUSE WHO MEETS CRITERIA)
22		F. OTHER: SPECIAL REASON SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
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24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

CLAIMANT MAILING ADDRESS

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1	C	MCS CLAIMANT MAILING ADDRESS CADR SC9	0
2	0	NH: SSSSSSSSS SSSSS SSSSSSSSSS CL: SSSSSSSSS SSSSS SSSSSSSSSS
3	l
4	u
5	m
6	n	*ADDRESS 1: PPPPPPPPPPPPPPPPPPPPPP ADDRESS 2: PPPPPPPPPPPPPPPPPPPPPP
7	*	ADDRESS 3: PPPPPPPPPPPPPPPPPPPPPP ADDRESS 4: PPPPPPPPPPPPPPPPPPPPPP
8	o	*CITY: PPPPPPPPPPPPPPPPPPPPPP STATE: PP ZIP: PPPPP
9	n	STATE & COUNTY CODE: PPPPPP COUNTY: XXXXXXXXXXXXXXX
10	e
11		COUNTRY: PPPPPPPPPPPPPPPPPPPPPP CONSULAR CODE: PPP
12	r	FOREIGN POSTAL ZONE: PPPPPPPPPPPPPPP
13	e
14	s	BANK ACCOUNT (Y/N): X DIRECT EXPRESS (Y/N): X
15	e
16	r	DIRECT DEPOSIT ROUTING TRANSIT NUMBER: 999999999 ACCOUNT TYPE (C/S): A
17	v	DEPOSITOR ACCOUNT NUMBER: 99999999999999999
18	e
19	d
20		DOMESTIC PHONE: PPPPPPPPPP FOREIGN PHONE: PPPPPPPPPPPPPPP
21
22		TRANSFER TO: XXXX
23		**************(line 23 reserved for applications information)*****************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

MAILING ADDRESS

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1	C	MCS APPLICANT MAILING ADDRESS ADDR SC0	9
2	0	NH: SSSSSSSSS SSSSS SSSSSSSSSS CL: SSSSSSSSS SSSSS SSSSSSSSSS
3	l
4	u	APPLICANT NAME:
5	m
6	n	*ADDRESS 1: PPPPPPPPPPPPPPPPPPPPPP ADDRESS 2: PPPPPPPPPPPPPPPPPPPPPP
7	*	ADDRESS 3: PPPPPPPPPPPPPPPPPPPPPP ADDRESS 4: PPPPPPPPPPPPPPPPPPPPPP
8	o	*CITY: PPPPPPPPPPPPPPPPPPPPPP STATE: PP ZIP: PPPPP
9	n	STATE & COUNTY CODE: PPPPPP COUNTY: XXXXXXXXXXXXXXX
10	e
11		COUNTRY: PPPPPPPPPPPPPPPPPPPPPP CONSULAR CODE: PPP
12	r	FOREIGN POSTAL ZONE: PPPPPPPPPPPPPPP
13	e
14	s	ADDRESS EXPLANATION:XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
15	e	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
16	r	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
17	v
18	e
19	d
20		DOMESTIC PHONE: PPPPPPPPPP FOREIGN PHONE: PPPPPPPPPPPPPPP
21
22		TRANSFER TO: XXXX
23		**************(line 23 reserved for applications information)*****************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

MISCELLANEOUS MEDICARE

LnNo	0 1	1 2 3 4 5 6 7 7 234567890123456789012345678901234567890123456789012345678901234567890123456789	8 0
1	C	MCS TRANSFER TO: XXXX MISCELLANEOUS MEDICARE MEDI SC2	2
2	0	NH SSSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
3	l
4	u	SPOUSE RECEIVING PENSION/ANNUITY FROM CIVIL SERVICE/OPM (Y/N): X
5	m	IF YES, ENTER ANNUITY NUMBER: XXXXXXXXXX
6	n	IF YES, SPOUSE ENROLLED IN SMI WITH SSA (Y/N): X
7	*
8	o	COMPLETE THE FOLLOWING QUESTIONS ONLY IF CLAIMANT OR SPOUSE EMPLOYED BY
9	n	FEDERAL GOVERNMENT AFTER JUNE 1960:
10	e	COVERED UNDER A MEDICAL PLAN PROVIDED BY FEHBA OF 1959 (Y/N): X
11		IF NO, COMPLETE THE FOLLOWING:
12	r	WERE CLAIMANT AND SPOUSE BARRED FROM COVERAGE BECAUSE
13	e	EMPLOYMENT NOT LONG ENOUGH (Y/N): X
14	s	IF BARRED FROM COVERAGE, EXPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
15	e	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
16	r	IF NOT BARRED FROM COVERAGE, CLAIMANT OR SPOUSE EMPLOYED BY
17	v	FEDERAL GOVERNMENT AFTER FEBRUARY 15, 1965 (Y/N): X
18	e
19	d
20
21
22
23		**************(line 23 reserved for applications information)*****************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

CL MILITARY SERVICE

LnNo	0 1	1 2 3 4 5 6 7 7 234567890123456789012345678901234567890123456789012345678901234567890123456789	8 0
1	C	MCS CL MILITARY SERVICE CLMS SC2	3
2	0	NH: SSSSSSSSS SSSSS SSSSSSSSSS CL: SSSSSSSSS SSSSS SSSSSSSSSS
3	l	FIRST NAME USED IN SERVICE: XXXXXXXXXX MI: X LAST NAME: XXXXXXXXXXXXXXXXXXX
4	u	SERVICE NO: XXXXXXXXX
5	m	*RECEIVE OR ELIGIBLE FOR MIL OR CIV FEDERAL AGENCY BENEFIT (SELECT ONE): 9
6	n	1=CIVILIAN 2=MILITARY 3=BOTH 4=NONE
7	*	[ A/R BRANCH OF SERVICE START END N/E RANK PROOF
8	o	| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
9	n	| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
10	e	| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
11		| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
12	r	| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
13	e	| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
14	s	| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
15	e	| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
16	r	| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
17	v	| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
18	e
19	d	[JAPANESE INTERNEE START END PROOF HOURLY WAGE
20		| 999999 999999 X 99999999
21		| 999999 999999 X 99999999
22		PF1 FOR HELP MORE (Y/N): X PAGE: 1 TRANSFER TO: XXXX
23		**************(line 23 reserved for applications information)*****************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

CL MILITARY RETIREMENT/FEDERAL BENEFIT

LnNo	0 1	1 2 3 4 5 6 7 7 234567890123456789012345678901234567890123456789012345678901234567890123456789	8 0
1	C	MCS TRANSFER TO: XXXX CL MILITARY RETIREMENT/FEDERAL BENEFIT CLMR SC2	6
2	0	NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
3	l
4	u	IF RETIRED FROM MILITARY, BASIS OF RETIREMENT: 9
5	m	1. LENGTH OF SERVICE 3. RESERVE SERVICE PAYABLE AT AGE 60
6	n	2. DISABILITY 4. OTHER
7	*	IF OPTION 4 CHOSEN, ESPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXX
8	o	IF RETIRED AND SERVICE AFTER DEC 31, 1956, INDICATE BRANCH OF SERVICE PAYING
9	n	BENEFIT: 9 1. ARMY 5. COAST GUARD
10	e	2. NAVY 6. PUBLIC HEALTH SERVICE
11		3. AIR FORCE 7. COASTAL/GEODETIC SURVEY
12	r	4. MARINE CORPS 8. OTHER
13	e	IF OPTION 8 CHOSEN, ESPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXX
14	s	WAIVED ALL/PART OF RETIREMENT TO GET VA OR OTHER FED CREDIT (Y/N): X
15	e
16	r	IF ELIGIBLE FOR CIVILIAN FEDERAL AGENCY BENEFITS, INDICATE BENEFIT TYPE: 9
17	v	1. SERVICE 2. SURVIVOR 3. DISABILITY 4. OTHER
18	e	IF OPTION 4 CHOSEN, ESPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXX
19	d	NAME OF FED AGENCY: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
20		YEARS EMPLOYED: 99 DATE CLAIM FILED: 999999 CLAIM NO.: XXXXXXXXXXXXX
21		MOST RECENT AGENCY: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
22		CITY: XXXXXXXXXXXXX STATE: XX LAST WORKED: 999999
23		**************(line 23 reserved for applications information)*****************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

RECORD OF CHANGE

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1	C	MCS TRANSFER TO: RECORD OF CHANGE CHNG SC3	8
2	0	NH 999999999 SSSSS SSSSSSSSSS CL 999999999 SSSSS SSSSSSSSSS
3	l
4	u	ELEMENT CHANGED OLD DATA DATE NAME PO	S
5	m
6	n	SSSSSSSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSSSSSSSSSS SSSSSS SSSSSSSS S	S
7	*	WHY: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX	X
8	o
9	n	SSSSSSSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSSSSSSSSSS SSSSSS SSSSSSSS S	S
10	e	WHY: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX	X
11
12	r	SSSSSSSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSSSSSSSSSS SSSSSS SSSSSSSS S	S
13	e	WHY: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX	X
14	s
15	e	SSSSSSSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSSSSSSSSSS SSSSSS SSSSSSSS S	S
16	r	WHY: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX	X
17	v
18	e	SSSSSSSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSSSSSSSSSS SSSSSS SSSSSSSS S	S
19	d	WHY: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX	X
20
21		MORE (Y//N): Y PAGE 01
22
23		**************(line 23 reserved for applications information)*****************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

REMARKS SCREEN

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1	C	MCS TRANSFER TO: XXXX REMARKS SCREEN RMKS SC4	2
2	0	NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
3	l
4	u	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
5	m	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
6	n	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
7	*	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
8	o	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
9	n	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
10	e	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
11		XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
12	r	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
13	e	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
14	s	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
15	e	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
16	r	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
17	v	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
18	e	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
19	d	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
20		XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
21		XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
22		MORE (Y/N): S GO TO RPS (Y/N): N PAGE SS
23		**************(line 23 reserved for applications information)*****************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

CASE RECORD OF CHANGE

LnNo	0 1	1 2 3 4 5 6 7 7 234567890123456789012345678901234567890123456789012345678901234567890123456789	8 0
1	C	MCS TRANSFER TO: XXXX CASE RECORD OF CHANGE CROC SC3	9
2	0	NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
3	l
4	u	ELEMENT CHANGED OLD DATA DATE NAME PO	S
5	m
6	n	SSSSSS SSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSSSSSSSSSS SSSSSS SSSSSS S S	S
7	*	APPLICANT WHO ALLEGED DATA: SSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
8	o
9	n	SSSSSS SSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSSSSSSSSSS SSSSSS SSSSSS S S	S
10	e	APPLICANT WHO ALLEGED DATA: SSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
11
12	r	SSSSSS SSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSSSSSSSSSS SSSSSS SSSSSS S S	S
13	e	APPLICANT WHO ALLEGED DATA: SSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
14	s
15	e	SSSSSS SSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSSSSSSSSSS SSSSSS SSSSSS S S	S
16	r	APPLICANT WHO ALLEGED DATA: SSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
17	v
18	e	SSSSSS SSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSSSSSSSSSS SSSSSS SSSSSS S S	S
19	d	APPLICANT WHO ALLEGED DATA: SSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
20
21
22		MORE (Y/N): S PAGE S
23		**************(line 23 reserved for applications information)*****************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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MCS

NUMIDENT/DEATH ALERT

LnNo	0 1	1 2 3 4 5 6 7 7 234567890123456789012345678901234567890123456789012345678901234567890123456789	8 0
1	C	MCS NUMIDENT/DEATH ALERT ERFA SC6	1
2	0	NH SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS CL SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS
3	l
4	u	DATA ENTERED FOR NH NUMIDENT DATA
5	m	SSN: SSSSSSSSS
6	n	NAME: SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS NAME: SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS	S
7	*	DATE OF BIRTH: SSSSSS DATE OF BIRTH: SSSSSS
8	o	SEX: S SEX: S
9	n	DATE OF DEATH: SSSSSS
10	e
11
12	r	DATA ENTERED FOR CL NUMIDENT DATA
13	e	SSN: SSSSSSSSS
14	s	NAME: SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS NAME: SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS	S
15	e	DATE OF BIRTH: SSSSSS DATE OF BIRTH: SSSSSS
16	r	SEX: S SEX: S
17	v	DATE OF DEATH: SSSSSS
18	e
19	d
20
21
22
23		**************(line 23 reserved for applications information)*****************
24		**************(Line 24 Reserved for Operating Systems Information)***********

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