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stroke-width: 1.5px; stroke: rgb(0, 0, 0);"></rect></svg></div></div><div class="xfaWrapper" style="top: 756px; left: 532.37px; width: 61.63px; height: 12px; position: absolute; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 0px;" data-element-id="draw10590" class="xfaDraw xfaFont xfaWrapped" xfaname="Pages"><div style="display: flex; flex-direction: column; justify-content: center; text-align: right; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p>Page<span> </span> of<span> </span></p></div></div></div><div class="xfaWrapper" style="top: 756px; left: 18.39px; width: 184.5px; height: 12px; position: absolute; align-self: start;"><div class="xfaBorder" style="top: -0.288px; left: -0.288px; width: calc(100% + 0.576px); height: calc(100% + 0.576px); border-width: 0.58px; border-color: rgb(0, 0, 0); border-style: none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 0px 3.6px;" data-element-id="draw10599" class="xfaDraw xfaFont xfaWrapped" xfaname="FormNumber_Date"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: end; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>DD FORM 2656, MARCH 2022</span></div></div></div><div class="xfaWrapper" style="top: 10.44px; left: 223.2px; width: 368.4px; height: 781.56px; position: absolute; align-self: start;"><div data-element-id="subform10613" class="xfaSubform xfaPosition xfaWrapped"><div class="xfaWrapper" style="top: 759.96px; left: 0px; width: 165.6px; height: 12.24px; position: absolute; align-self: start;"><div class="xfaBorder" style="top: -0.288px; left: -0.288px; width: calc(100% + 0.576px); height: calc(100% + 0.576px); border-width: 0.58px; border-color: rgb(0, 0, 0); border-style: none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 0px 3.6px;" data-element-id="draw10615" class="xfaDraw xfaFont xfaWrapped" xfaname="SecessionNotice"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: end; text-align: center; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>PREVIOUS EDITION IS OBSOLETE.</span></div></div></div><div class="xfaWrapper" style="top: 745.56px; left: 28.8px; width: 108px; height: 14.4px; position: absolute; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 0px;" data-element-id="draw10629" class="xfaDraw xfaFont xfaWrapped" xfaname="CUIfooter" title="Document classification when filled in is CUI"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="text-align: center; text-decoration: none; letter-spacing: 0px;">CUI (when filled in)</p></div></div></div><div class="xfaWrapper" style="top: 0px; left: 28.8px; width: 108px; height: 14.4px; position: absolute; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 0px;" data-element-id="draw10640" class="xfaDraw xfaFont xfaWrapped" xfaname="CUIheader" title="Document classification when filled in is CUI"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="text-align: center; text-decoration: none; letter-spacing: 0px;">CUI (when filled in)</p></div></div></div><div class="xfaWrapper" style="top: 747.72px; left: 206.64px; width: 161.76px; height: 33.84px; position: absolute; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 6.43px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 0px;" data-element-id="draw10651" class="xfaDraw xfaFont xfaWrapped" xfaname="CUIField"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><p><span>Controlled by: OUSD(P&R)</span><br></p><p><span>CUI Category: PRVCY</span><br></p><p><span>LDC: FEDCON</span><br></p><p><span>POC: osd.pentagon.ousd-p-r.mbx.forms@mail.mil</span><br></p></div></div></div></div></div><div style="left: 18px; top: 25.2px; width: 576px; height: 730.8px;" class="xfaContentarea" data-element-id="contentArea10545"><div data-element-id="subform10542" class="xfaSubform xfaTb" style="width: auto; height: auto; position: absolute; left: 0px; top: 0px; align-self: start;" xfaname="form1"><div class="xfaWrapper" style="width: 576px; height: 730.71px; position: relative; align-self: start;"><div data-element-id="subform11166" class="xfaSubform xfaLrTb xfaWrapped" xfaname="page1"><div class="xfaLr"><div class="xfaWrapper" style="width: 488.88px; height: 29.52px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.799921px); height: calc(100% + 0.799921px); border-width: 0.5px 1.1px 1.1px 0.5px; border-color: rgb(0, 0, 0); border-style: none solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw11167" class="xfaDraw xfaFont xfaWrapped" xfaname="Title" role="heading" aria-level="1"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: center; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span> DATA FOR PAYMENT OF RETIRED PERSONNEL</span></div></div></div><div class="xfaWrapper" style="width: 87.12px; height: 29.52px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.799921px); height: calc(100% + 0.799921px); border-width: 0.5px 1.1px 1.1px 0.5px; border-color: rgb(0, 0, 0); border-style: none solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: italic; font-size: 6.93px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 1.42px 1.42px 1.42px 7.2px;" data-element-id="draw11185" class="xfaDraw xfaFont xfaWrapped" xfaname="OMB" role="heading" aria-level="1"><div style="display: flex; flex-direction: column; justify-content: center; text-align: center; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="text-align: left; letter-spacing: 0px;">OMB No. 0704-0569<span> </span></p><p style="text-align: left; letter-spacing: 0px;">OMB approval expires:</p><p style="text-align: left; letter-spacing: 0px;">20260831</p></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 33.45px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.799921px); border-width: 0.5px 0.5px 1.1px; border-color: rgb(0, 0, 0); border-style: none none solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 5.94px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 3.6px 1.42px 1.42px;" data-element-id="draw11203" class="xfaDraw xfaFont xfaWrapped" xfaname="ADN" role="heading" aria-level="1"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: start; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>The public reporting burden for this collection of information, 0704-0569, is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.</span></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 109.62px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 6.93px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 1.42px 3.6px 1.42px 1.42px;" data-element-id="draw11221" class="xfaDraw xfaFont xfaWrapped" xfaname="PrivacyActStatement"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 3.6px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="margin-bottom: 3px; text-align: center; font-weight: bold; letter-spacing: 0px;">PRIVACY ACT STATEMENT</p><p style="margin-bottom: 3px; font-weight: bold; letter-spacing: 0px;">AUTHORITY:<span style="font-weight: normal;"> 10 United States Code (U.S.C.) Chapter 71, Computation of Retired Pay; 10 U.S.C. 73, Annuities Based On Retired Or Retainer Pay; DoD Instruction 1332.42, Survivor Benefit Plan; and DoD Financial Management Regulation, 7000.14-R, Volume 7B.</span></p><p style="margin-bottom: 3px; font-weight: bold; letter-spacing: 0px;">PRINCIPAL PURPOSE(S):<span style="font-weight: normal;"> To collect information needed to establish a retired/retainer pay account, including designation of beneficiaries for unpaid retired pay, state tax withholding election, information on dependents, and to establish a Survivor Benefit Plan election.</span></p><p style="margin-bottom: 3px; font-weight: bold; letter-spacing: 0px;">ROUTINE USE(S):<span> </span><span style="font-weight: normal;">To the Department of Veterans Affairs (DVA) regarding establishments, changes and discontinuing of DVA compensation to retirees and annuitants. To former spouses for purposes of providing information, consistent with the requirements of 10 U.S.C. 1450(f)(3), regarding Survivor Benefit Plan coverage. To spouses for purposes of providing information, consistent with the requirements of 10 U.S.C. 1448(a), regarding Survivor Benefit Plan coverage.<span> </span>Additional routine uses are available in the applicable system of records notice T7347b, Defense Military Retiree and Annuity Pay System Records, available at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570196/t7347b/</span></p><p style="font-weight: bold; letter-spacing: 0px;">DISCLOSURE:<span style="font-weight: normal;"> Voluntary; however, failure to provide requested information will result in delays in initiating retired/retainer pay.</span></p></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 23.47px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.500032px; left: -0.749055px; width: calc(100% + 1.4991px); height: calc(100% + 1.00006px); border-width: 1px 1.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: normal; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; background-color: rgb(192, 192, 192); padding: 1.42px 1.42px 1.42px 7.2px;" data-element-id="draw11232" class="xfaDraw xfaFont xfaWrapped" xfaname="Warning" role="heading" aria-level="1"><div style="display: flex; flex-direction: column; justify-content: center; text-align: center; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="letter-spacing: 0px;">WARNING</p><p style="font-style: italic; letter-spacing: 0px;">Read the instructions at the end of this form in their entirety prior to completing.</p></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 21.6px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.799921px); height: calc(100% + 0.799921px); border-width: 0.5px 1.1px 1.1px 0.5px; border-color: rgb(0, 0, 0); border-style: none solid solid none;"></div><div style="font-kerning: normal; letter-spacing: 0px; font-style: normal; font-size: 10.89px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px 1.42px 1.42px 7.2px;" data-element-id="draw11252" class="xfaDraw xfaFont xfaWrapped" xfaname="Part1" role="heading" aria-level="1"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: center; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>PART I - RETIRED PAY INFORMATION</span></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 272.41px; position: relative; align-self: start;"><div data-element-id="subform11270" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Section1Block"><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 14.4px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.500457px; left: -0.749055px; width: calc(100% + 1.49811px); height: calc(100% + 1.00091px); border-width: 1px 1.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: normal; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; background-color: rgb(192, 192, 192); padding: 1.42px 1.42px 1.42px 7.2px;" data-element-id="draw11271" class="xfaDraw xfaFont xfaWrapped" xfaname="Section1" role="heading" aria-level="1"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>SECTION I - PAY IDENTIFICATION</span></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 282.96px; height: 43.2px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field11291" class="xfaField xfaFont xfaWrapped" xfaname="mbrName" title="PART I - RETIRED PAY INFORMATION - SECTION I - PAY IDENTIFICATION - 1. NAME (Last, First, Middle Initial)"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 7.2px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">1. NAME<span> </span><span style="font-size: 6.93px; font-weight: normal; font-style: italic;">(Last, First, Middle Initial)</span></p></div></div><textarea fieldid="field11291" class="xfaTextfield" style="height: 31.36px;" aria-label="PART I - RETIRED PAY INFORMATION - SECTION I - PAY IDENTIFICATION - 1. NAME (Last, First, Middle Initial)" aria-required="false" tabindex="5000"></textarea></label></div></div><div class="xfaWrapper" style="width: 93.6px; height: 43.2px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.248457px; left: -0.248457px; width: calc(100% + 0.496913px); height: calc(100% + 0.496913px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field11313" class="xfaField xfaFont xfaWrapped" xfaname="mbrSSN" title="2. Social security number. Do not include dashes."><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 3.6px;"><span>2. SSN</span></div></div><input type="text" fieldid="field11313" class="xfaTextfield" style="height: 31.36px;" aria-label="2. Social security number. Do not include dashes." aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 80.64px; height: 43.2px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field11343" class="xfaField xfaFont xfaWrapped" xfaname="DOB3" title="Enter your Date of Birth here in format YYYYMMDD."><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 18px;" class="xfaCaption"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 3.6px;" class="xfaRich"><p style="line-height: 7px; letter-spacing: 0px;">3. DATE OF BIRTH<span> </span></p><p style="letter-spacing: 0px;"><span> </span><span style="font-size: 6.93px; font-weight: normal; font-style: italic;">(YYYYMMDD)</span></p></div></div><input type="text" fieldid="field11343" class="xfaTextfield" style="height: 22.36px;" aria-label="Enter your Date of Birth here in format YYYYMMDD." aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 118.8px; height: 43.2px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field11371" class="xfaField xfaFont xfaWrapped" xfaname="RetirementDate4" title="Enter retirement/transfer date in format YYYYMMDD."><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 18px;" class="xfaCaption"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 3.6px;" class="xfaRich"><p style="line-height: 8px; text-decoration: none; letter-spacing: 0px;">4. RETIREMENT / TRANSFER<span> </span></p><p style="line-height: 7px; text-decoration: none; letter-spacing: 0px;"><span> </span>DATE<span> </span><span style="font-size: 6.93px; font-weight: normal; font-style: italic;">(YYYYMMDD)</span></p></div></div><input type="text" fieldid="field11371" class="xfaTextfield" style="height: 22.36px;" aria-label="Enter retirement/transfer date in format YYYYMMDD." aria-required="false" tabindex="5000"></label></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 122.4px; height: 32.22px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field11400" class="xfaField xfaFont xfaWrapped" xfaname="Rank5"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 7.2px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>5. PAY GRADE</span></div></div><input type="text" fieldid="field11400" class="xfaTextfield" style="height: 20.38px;" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 453.6px; height: 32.39px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div data-element-id="subform11420" class="xfaSubform xfaLrTb xfaWrapped" xfaname="BranchOfServ6"><div class="xfaLr"><div class="xfaWrapper" style="width: 108px; height: 16.13px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none none solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 0px 1.42px 0px 7.2px;" data-element-id="draw11421" class="xfaDraw xfaFont xfaWrapped" xfaname="BranchOfServ"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>6. BRANCH OF SERVICE</span></div></div></div><div class="xfaWrapper" style="width: 345.6px; height: 32.39px; position: relative; align-self: start;"><div data-element-id="subform11439" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Checklist"><div class="xfaLr"><div class="xfaWrapper" style="width: 75.6px; height: 16.19px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field11440" class="xfaField xfaFont xfaWrapped" xfaname="a" title="6. BRANCH OF SERVICE - Select for "branch of service - Army.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 56px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left;" class="xfaRich"><p style="letter-spacing: 0px;">a.<span> </span><span style="font-weight: bold;">ARMY</span></p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field11440" type="checkbox" xfaon="1" xfaoff="0" aria-label="6. BRANCH OF SERVICE - Select for "branch of service - Army."" aria-required="false" tabindex="5000" value="0"></label></div></div><div class="xfaWrapper" style="width: 93.6px; height: 16.19px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field11469" class="xfaField xfaFont xfaWrapped" xfaname="b" title="6. BRANCH OF SERVICE - Select for "branch of service - Marine Corps.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 74px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left;" class="xfaRich"><p style="letter-spacing: 0px;">b.<span> </span><span style="font-weight: bold;">MARINE CORPS</span></p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field11469" type="checkbox" xfaon="1" xfaoff="0" aria-label="6. BRANCH OF SERVICE - Select for "branch of service - Marine Corps."" aria-required="false" tabindex="5000" value="0"></label></div></div><div class="xfaWrapper" style="width: 56.84px; height: 16.19px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field11498" class="xfaField xfaFont xfaWrapped" xfaname="c" title="6. BRANCH OF SERVICE - Select for "branch of service - Navy.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 37px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">c.<span> </span><span style="font-weight: bold;">NAVY</span></p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field11498" type="checkbox" xfaon="1" xfaoff="0" aria-label="6. BRANCH OF SERVICE - Select for "branch of service - Navy."" aria-required="false" tabindex="5000" value="0"></label></div></div><div class="xfaWrapper" style="width: 91.44px; height: 16.19px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field11527" class="xfaField xfaFont xfaWrapped" xfaname="d" title="6. BRANCH OF SERVICE - Select for "branch of service - Coast Guard.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 72px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left;" class="xfaRich"><p style="letter-spacing: 0px;">d.<span> </span><span style="font-weight: bold;">COAST GUARD</span></p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field11527" type="checkbox" xfaon="1" xfaoff="0" aria-label="6. BRANCH OF SERVICE - Select for "branch of service - Coast Guard."" aria-required="false" tabindex="5000" value="0"></label></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 75.6px; height: 16.19px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field11556" class="xfaField xfaFont xfaWrapped" xfaname="e" title="6. BRANCH OF SERVICE - Select for "branch of service - Air Force.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 56px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">e.<span> </span><span style="font-weight: bold;">AIR FORCE</span></p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field11556" type="checkbox" xfaon="1" xfaoff="0" aria-label="6. BRANCH OF SERVICE - Select for "branch of service - Air Force."" aria-required="false" tabindex="5000" value="0"></label></div></div><div class="xfaWrapper" style="width: 93.6px; height: 16.19px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field11585" class="xfaField xfaFont xfaWrapped" xfaname="f" title="6. BRANCH OF SERVICE - Select for "branch of service - Space Force.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 74px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left;" class="xfaRich"><p style="letter-spacing: 0px;">f.<span> </span><span style="font-weight: bold;">SPACE FORCE</span></p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field11585" type="checkbox" xfaon="1" xfaoff="0" aria-label="6. BRANCH OF SERVICE - Select for "branch of service - Space Force."" aria-required="false" tabindex="5000" value="0"></label></div></div><div class="xfaWrapper" style="width: 56.84px; height: 16.19px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field11614" class="xfaField xfaFont xfaWrapped" xfaname="g" title="6. BRANCH OF SERVICE - Select for "branch of service - NOAA.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 37px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">g.<span> </span><span style="font-weight: bold;">NOAA</span></p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field11614" type="checkbox" xfaon="1" xfaoff="0" aria-label="6. BRANCH OF SERVICE - Select for "branch of service - NOAA."" aria-required="false" tabindex="5000" value="0"></label></div></div><div class="xfaWrapper" style="width: 75.45px; height: 16.19px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field11643" class="xfaField xfaFont xfaWrapped" xfaname="h1" title="6. BRANCH OF SERVICE - Select for "branch of service - USPHS.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 56px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left;" class="xfaRich"><p style="letter-spacing: 0px;">h.<span> </span><span style="font-weight: bold;">USPHS</span></p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field11643" type="checkbox" xfaon="1" xfaoff="0" aria-label="6. BRANCH OF SERVICE - Select for "branch of service - USPHS."" aria-required="false" tabindex="5000" value="0"></label></div></div></div></div></div></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 177.84px; height: 108.98px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div data-element-id="subform11683" class="xfaSubform xfaLrTb xfaWrapped" xfaname="MemberOf7"><div class="xfaLr"><div class="xfaWrapper" style="width: 177.84px; height: 12.61px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 0px 1.42px 0px 7.2px;" data-element-id="draw11684" class="xfaDraw xfaFont xfaWrapped" xfaname="BranchOfServ"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>7. MEMBER OR FORMER MEMBER OF THE</span></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 16.56px; height: 72px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw11702" class="xfaDraw xfaFont xfaWrapped" xfaname="buffer"></div></div><div class="xfaWrapper" style="width: 161.28px; height: 96.37px; position: relative; align-self: start;"><div data-element-id="subform11707" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Checklist"><div class="xfaLr"><div class="xfaWrapper" style="width: 161.28px; height: 16.56px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field11708" class="xfaField xfaFont xfaWrapped" xfaname="a" title="7. MEMBER OR FORMER MEMBER OF THE - Select for "regular component.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 142px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left;" class="xfaRich"><p style="letter-spacing: 0px;">a.<span> </span><span style="font-weight: bold;">REGULAR COMPONENT</span></p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field11708" type="checkbox" xfaon="1" xfaoff="0" aria-label="7. MEMBER OR FORMER MEMBER OF THE - Select for "regular component."" aria-required="false" tabindex="5000" value="0"></label></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 161.28px; height: 16.56px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field11737" class="xfaField xfaFont xfaWrapped" xfaname="b" title="7. MEMBER OR FORMER MEMBER OF THE - Select for "reserve component.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 142px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; text-indent: -7.2px; padding-left: 7.2px;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">b.<span> </span><span style="font-weight: bold;">RESERVE COMPONENT</span></p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field11737" type="checkbox" xfaon="1" xfaoff="0" aria-label="7. MEMBER OR FORMER MEMBER OF THE - Select for "reserve component."" aria-required="false" tabindex="5000" value="0"></label></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 161.28px; height: 24.17px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: italic; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; font-weight: normal; padding: 0px 1.42px;" data-element-id="draw11766" class="xfaDraw xfaFont xfaWrapped" xfaname="bText"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 18px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px; line-height: 8px;"><span> (all members of the Reserves and National Guard including Active Guard/Reserve and Full-Time Support)</span></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 159.24px; height: 17.01px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px 0px 21.6px;" data-element-id="field11774" class="xfaField xfaFont xfaWrapped" xfaname="rRet" title="7. MEMBER OR FORMER MEMBER OF THE - Select for "reserve component - regular retirement.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; width: 114px;" class="xfaCaptionForCheckButton"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 3.6px;"><span>(1) REGULAR RETIREMENT</span></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field11774" type="checkbox" xfaon="1" xfaoff="0" aria-label="7. MEMBER OR FORMER MEMBER OF THE - Select for "reserve component - regular retirement."" aria-required="false" tabindex="5000" value="0"></label></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 159.24px; height: 22.07px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px 0px 21.6px;" data-element-id="field11803" class="xfaField xfaFont xfaWrapped" xfaname="nrRet" title="7. MEMBER OR FORMER MEMBER OF THE - Select for "reserve component - non-regular retirement.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; width: 114px;" class="xfaCaptionForCheckButton"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 3.6px;"><p><span>(2) NON-REGULAR </span><br></p><p><span> RETIREMENT</span><br></p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field11803" type="checkbox" xfaon="1" xfaoff="0" aria-label="7. MEMBER OR FORMER MEMBER OF THE - Select for "reserve component - non-regular retirement."" aria-required="false" tabindex="5000" value="0"></label></div></div></div></div></div></div></div></div><div class="xfaWrapper" style="width: 398.16px; height: 90.29px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid none;"></div><div data-element-id="subform11843" class="xfaSubform xfaLrTb xfaWrapped" xfaname="RetirementPlan8"><div class="xfaLr"><div class="xfaWrapper" style="width: 398.16px; height: 18.29px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 0px 1.42px 0px 7.2px;" data-element-id="draw11844" class="xfaDraw xfaFont xfaWrapped" xfaname="RetirementPlan"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="letter-spacing: 0px;">8. PARTICIPANT IN THE FOLLOWING RETIREMENT PLAN<span> </span><span style="font-weight: normal; font-style: italic;">(See instructions, check only one)</span></p></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 16.56px; height: 72px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw11862" class="xfaDraw xfaFont xfaWrapped" xfaname="buffer"></div></div><div class="xfaWrapper" style="width: 381.6px; height: 72px; position: relative; align-self: start;"><div data-element-id="subform11867" class="xfaSubform xfaTb xfaWrapped" xfaname="Checklist"><div class="xfaWrapper" style="width: 381.6px; height: 14.4px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field11868" class="xfaField xfaFont xfaWrapped" xfaname="a" title="8. PARTICIPANT IN THE FOLLOWING RETIREMENT PLAN - Select for "FINAL PAY (only those members who first joined the service prior to September 8, 1980).""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 362px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left;" class="xfaRich"><p style="letter-spacing: 0px;">a.<span> </span><span style="font-weight: bold;">FINAL PAY</span><span> </span><span style="font-size: 6.93px; font-style: italic;">(only those members who first joined the service prior to September 8, 1980)</span></p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field11868" type="checkbox" xfaon="1" xfaoff="0" aria-label="8. PARTICIPANT IN THE FOLLOWING RETIREMENT PLAN - Select for "FINAL PAY (only those members who first joined the service prior to September 8, 1980)."" aria-required="false" tabindex="5000" value="0"></label></div></div><div class="xfaWrapper" style="width: 381.6px; height: 14.4px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field11897" class="xfaField xfaFont xfaWrapped" xfaname="b" title="8. PARTICIPANT IN THE FOLLOWING RETIREMENT PLAN - Select for "HIGH-3 (also known as the "High 36").""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 362px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">b.<span> </span><span style="font-weight: bold;">HIGH-3 (also known as the "High 36")</span></p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field11897" type="checkbox" xfaon="1" xfaoff="0" aria-label="8. PARTICIPANT IN THE FOLLOWING RETIREMENT PLAN - Select for "HIGH-3 (also known as the "High 36")."" aria-required="false" tabindex="5000" value="0"></label></div></div><div class="xfaWrapper" style="width: 381.6px; height: 14.4px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field11926" class="xfaField xfaFont xfaWrapped" xfaname="c" title="8. PARTICIPANT IN THE FOLLOWING RETIREMENT PLAN - Select for "CSB/REDUX (only members who elected the Career Status Bonus upon completion of 15 years of service).""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 362px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; text-indent: -7.2px; padding-left: 7.2px;" class="xfaRich"><p style="letter-spacing: 0px;">c.<span> </span><span style="font-weight: bold;">CSB/REDUX</span><span> </span><span style="font-size: 6.93px; font-style: italic;">(only members who elected the Career Status Bonus upon completion of 15 years of service)</span></p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field11926" type="checkbox" xfaon="1" xfaoff="0" aria-label="8. PARTICIPANT IN THE FOLLOWING RETIREMENT PLAN - Select for "CSB/REDUX (only members who elected the Career Status Bonus upon completion of 15 years of service)."" aria-required="false" tabindex="5000" value="0"></label></div></div><div class="xfaWrapper" style="width: 381.6px; height: 14.4px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field11955" class="xfaField xfaFont xfaWrapped" xfaname="d" title="8. PARTICIPANT IN THE FOLLOWING RETIREMENT PLAN - Select for "BLENDED RETIREMENT SYSTEM (BRS).""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 362px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">d.<span> </span><span style="font-weight: bold;">BLENDED RETIREMENT SYSTEM (BRS)</span></p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field11955" type="checkbox" xfaon="1" xfaoff="0" aria-label="8. PARTICIPANT IN THE FOLLOWING RETIREMENT PLAN - Select for "BLENDED RETIREMENT SYSTEM (BRS)."" aria-required="false" tabindex="5000" value="0"></label></div></div><div class="xfaWrapper" style="width: 381.6px; height: 14.4px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field11984" class="xfaField xfaFont xfaWrapped" xfaname="e" title="8. PARTICIPANT IN THE FOLLOWING RETIREMENT PLAN - Select for "DISABILITY.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 362px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">e.<span> </span><span style="font-weight: bold;">DISABILITY</span></p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field11984" type="checkbox" xfaon="1" xfaoff="0" aria-label="8. PARTICIPANT IN THE FOLLOWING RETIREMENT PLAN - Select for "DISABILITY."" aria-required="false" tabindex="5000" value="0"></label></div></div></div></div></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 73.44px; position: relative; align-self: start;"><div data-element-id="subform12030" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Block9"><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 15.84px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.551055px; left: -0.25px; width: calc(100% + 0.799921px); height: calc(100% + 0.799512px); border-width: 1.1px 1.1px 0.5px 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid solid none;"></div><div style="font-kerning: normal; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px 1.42px 1.42px 7.2px;" data-element-id="draw12031" class="xfaDraw xfaFont xfaWrapped" xfaname="Address9" role="heading" aria-level="1"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="letter-spacing: 0px;">9. ADDRESS<span style="font-weight: normal; font-style: italic;"> (Ensure DFAS - Cleveland Center, or the Coast Guard PPC for non-DOD members, is advised whenever your correspondence address changes)</span></p></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 216px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field12049" class="xfaField xfaFont xfaWrapped" xfaname="Street" title="9. ADDRESS - a. STREET (Include apartment number)"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 7.2px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">a. STREET<span> </span><span style="font-weight: normal; font-style: italic;">(Include apartment number)</span></p></div></div><input type="text" fieldid="field12049" class="xfaTextfield" style="height: 16.96px;" aria-label="9. ADDRESS - a. STREET (Include apartment number)" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 144px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field12070" class="xfaField xfaFont xfaWrapped" xfaname="City" title="9. ADDRESS - b. CITY"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 7.2px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>b. CITY</span></div></div><input type="text" fieldid="field12070" class="xfaTextfield" style="height: 16.96px;" aria-label="9. ADDRESS - b. CITY" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 46.8px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.358px); border-width: 0.5px 0.5px 0.22px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field12091" class="xfaField xfaFont xfaWrapped" xfaname="State" title="9. ADDRESS - c. STATE (select from drop-down list)"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 3.6px;" class="xfaRich"><p style="margin-left: 3.6px; text-decoration: none; letter-spacing: 0px;">c. STATE</p></div></div><select class="xfaSelect" fieldid="field12091" style="border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 15.96px;" aria-label="9. ADDRESS - c. STATE (select from drop-down list)" aria-required="false" tabindex="5000"><option selected="true" hidden="true"> </option><option value="AK" style="font-size: calc(10px * var(--scale-factor));">AK</option><option value="AL" style="font-size: calc(10px * var(--scale-factor));">AL</option><option value="0" style="font-size: calc(10px * var(--scale-factor));">AP</option><option value="AR" style="font-size: calc(10px * var(--scale-factor));">AR</option><option value="AZ" style="font-size: calc(10px * var(--scale-factor));">AZ</option><option value="CA" style="font-size: calc(10px * var(--scale-factor));">CA</option><option value="CO" style="font-size: calc(10px * var(--scale-factor));">CO</option><option value="CT" style="font-size: calc(10px * var(--scale-factor));">CT</option><option value="DC" style="font-size: calc(10px * var(--scale-factor));">DC</option><option value="DE" style="font-size: calc(10px * var(--scale-factor));">DE</option><option value="FL" style="font-size: calc(10px * var(--scale-factor));">FL</option><option value="GA" style="font-size: calc(10px * var(--scale-factor));">GA</option><option value="HI" style="font-size: calc(10px * var(--scale-factor));">HI</option><option value="IA" style="font-size: calc(10px * var(--scale-factor));">IA</option><option value="ID" style="font-size: calc(10px * var(--scale-factor));">ID</option><option value="IL" style="font-size: calc(10px * var(--scale-factor));">IL</option><option value="IN" style="font-size: calc(10px * var(--scale-factor));">IN</option><option value="KS" style="font-size: calc(10px * var(--scale-factor));">KS</option><option value="KY" style="font-size: calc(10px * var(--scale-factor));">KY</option><option value="LA" style="font-size: calc(10px * var(--scale-factor));">LA</option><option value="MA" style="font-size: calc(10px * var(--scale-factor));">MA</option><option value="MD" style="font-size: calc(10px * var(--scale-factor));">MD</option><option value="ME" style="font-size: calc(10px * var(--scale-factor));">ME</option><option value="MI" style="font-size: calc(10px * var(--scale-factor));">MI</option><option value="MN" style="font-size: calc(10px * var(--scale-factor));">MN</option><option value="MO" style="font-size: calc(10px * var(--scale-factor));">MO</option><option value="MS" style="font-size: calc(10px * var(--scale-factor));">MS</option><option value="MT" style="font-size: calc(10px * var(--scale-factor));">MT</option><option value="NC" style="font-size: calc(10px * var(--scale-factor));">NC</option><option value="ND" style="font-size: calc(10px * var(--scale-factor));">ND</option><option value="NE" style="font-size: calc(10px * var(--scale-factor));">NE</option><option value="NH" style="font-size: calc(10px * var(--scale-factor));">NH</option><option value="NJ" style="font-size: calc(10px * var(--scale-factor));">NJ</option><option value="NM" style="font-size: calc(10px * var(--scale-factor));">NM</option><option value="NV" style="font-size: calc(10px * var(--scale-factor));">NV</option><option value="NY" style="font-size: calc(10px * var(--scale-factor));">NY</option><option value="OH" style="font-size: calc(10px * var(--scale-factor));">OH</option><option value="OK" style="font-size: calc(10px * var(--scale-factor));">OK</option><option value="OR" style="font-size: calc(10px * var(--scale-factor));">OR</option><option value="PA" style="font-size: calc(10px * var(--scale-factor));">PA</option><option value="RI" style="font-size: calc(10px * var(--scale-factor));">RI</option><option value="SC" style="font-size: calc(10px * var(--scale-factor));">SC</option><option value="SD" style="font-size: calc(10px * var(--scale-factor));">SD</option><option value="TN" style="font-size: calc(10px * var(--scale-factor));">TN</option><option value="TX" style="font-size: calc(10px * var(--scale-factor));">TX</option><option value="UT" style="font-size: calc(10px * var(--scale-factor));">UT</option><option value="VA" style="font-size: calc(10px * var(--scale-factor));">VA</option><option value="VT" style="font-size: calc(10px * var(--scale-factor));">VT</option><option value="WA" style="font-size: calc(10px * var(--scale-factor));">WA</option><option value="WI" style="font-size: calc(10px * var(--scale-factor));">WI</option><option value="WV" style="font-size: calc(10px * var(--scale-factor));">WV</option><option value="WY" style="font-size: calc(10px * var(--scale-factor));">WY</option></select></label></div></div><div class="xfaWrapper" style="width: 72px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field12223" class="xfaField xfaFont xfaWrapped" xfaname="ZipCode" title="9. ADDRESS - d. ZIP CODE"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span> d. ZIP CODE</span></div></div><input type="text" fieldid="field12223" class="xfaTextfield" style="border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 15.96px;" aria-label="9. ADDRESS - d. ZIP CODE" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 97.2px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field12255" class="xfaField xfaFont xfaWrapped" xfaname="Country" title="9. ADDRESS - e. COUNTRY"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span> e. COUNTRY</span></div></div><input type="text" fieldid="field12255" class="xfaTextfield" style="border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 15.96px;" aria-label="9. ADDRESS - e. COUNTRY" aria-required="false" tabindex="5000"></label></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 89.98px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field12280" class="xfaField xfaFont xfaWrapped" xfaname="apo" title="9. ADDRESS - f. APO/FPO"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span>f. APO/FPO</span></div></div><input type="text" fieldid="field12280" class="xfaTextfield" style="border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 15.96px;" aria-label="9. ADDRESS - f. APO/FPO" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 126px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field12303" class="xfaField xfaFont xfaWrapped" xfaname="Phone" title="9. ADDRESS - g. TELEPHONE (Include area code)"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">g. TELEPHONE<span> </span><span style="font-size: 6.93px; font-weight: normal; font-style: italic;">(Incl. area code)</span></p></div></div><input type="text" fieldid="field12303" class="xfaTextfield" style="border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 15.96px;" aria-label="9. ADDRESS - g. TELEPHONE (Include area code)" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 167.4px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field12331" class="xfaField xfaFont xfaWrapped" xfaname="Email" title="9. ADDRESS - h. EMAIL ADDRESS"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span>h. EMAIL ADDRESS</span></div></div><input type="text" fieldid="field12331" class="xfaTextfield" style="border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 15.96px;" aria-label="9. ADDRESS - h. EMAIL ADDRESS" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 189.36px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none solid solid;"></div><div data-element-id="subform12358" class="xfaSubform xfaLrTb xfaWrapped" xfaname="ContactMethod"><div class="xfaLr"><div class="xfaWrapper" style="width: 186.72px; height: 12.61px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw12359" class="xfaDraw xfaFont xfaWrapped" xfaname="Contact"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 5.76px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="margin-left: 5.76px; letter-spacing: 0px;">i. PREFERRED CONTACT METHOD<span> </span><span style="font-size: 6.93px; font-weight: normal; font-style: italic;">(check one)<span> </span></span></p></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 16.56px; height: 16.19px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw12367" class="xfaDraw xfaFont xfaWrapped" xfaname="buffer"></div></div><div class="xfaWrapper" style="width: 86.4px; height: 16.19px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field12372" class="xfaField xfaFont xfaWrapped" xfaname="phone" title="9. ADDRESS - i. PREFERRED CONTACT METHOD (check one) - Select for "telephone.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 67px;" class="xfaCaptionForCheckButton"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span>TELEPHONE</span></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field12372" type="checkbox" xfaon="1" xfaoff="0" aria-label="9. ADDRESS - i. PREFERRED CONTACT METHOD (check one) - Select for "telephone."" aria-required="false" tabindex="5000" value="0"></label></div></div><div class="xfaWrapper" style="width: 86.4px; height: 16.19px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field12401" class="xfaField xfaFont xfaWrapped" xfaname="email" title="9. ADDRESS - i. PREFERRED CONTACT METHOD (check one) - Select for "email.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 67px;" class="xfaCaptionForCheckButton"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span>EMAIL</span></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field12401" type="checkbox" xfaon="1" xfaoff="0" aria-label="9. ADDRESS - i. PREFERRED CONTACT METHOD (check one) - Select for "email."" aria-required="false" tabindex="5000" value="0"></label></div></div></div></div></div></div></div></div></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 101.89px; position: relative; align-self: start;"><div data-element-id="subform12451" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Section2Block"><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 14.4px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.500457px; left: -0.749055px; width: calc(100% + 1.49811px); height: calc(100% + 1.00091px); border-width: 1px 1.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: normal; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; background-color: rgb(192, 192, 192); padding: 1.42px 1.42px 1.42px 7.2px;" data-element-id="draw12452" class="xfaDraw xfaFont xfaWrapped" xfaname="Section2" role="heading" aria-level="1"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="letter-spacing: 0px;">SECTION II - DIRECT DEPOSIT / ELECTRONIC FUND TRANSFER (DD/EFT) INFORMATION<span> </span><span style="font-weight: normal; font-style: italic;">(See Instructions)</span></p></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 17.28px; position: relative; align-self: start;"><div data-element-id="subform12472" class="xfaSubform xfaLrTb xfaWrapped" xfaname="ADOnly"><div class="xfaLr"><div class="xfaWrapper" style="width: 16.56px; height: 17.28px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw12473" class="xfaDraw xfaFont xfaWrapped" xfaname="buffer"></div></div><div class="xfaWrapper" style="width: 559.44px; height: 17.28px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field12478" class="xfaField xfaFont xfaWrapped" xfaname="ActiveDutyOnly" title="SECTION II - DIRECT DEPOSIT / ELECTRONIC FUND TRANSFER (DD/EFT) INFORMATION (See Instructions) - Select for "ACTIVE DUTY ONLY: Check here if you want to continue using financial information currently on file, otherwise fill out Items 10 through 13).""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 540px;" class="xfaCaptionForCheckButton"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span>ACTIVE DUTY ONLY (check here if you want to continue using financial information currently on file, otherwise fill out Items 10 through 13)</span></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field12478" type="checkbox" xfaon="1" xfaoff="0" aria-label="SECTION II - DIRECT DEPOSIT / ELECTRONIC FUND TRANSFER (DD/EFT) INFORMATION (See Instructions) - Select for "ACTIVE DUTY ONLY: Check here if you want to continue using financial information currently on file, otherwise fill out Items 10 through 13)."" aria-required="false" tabindex="5000" value="0"></label></div></div></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 192px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div data-element-id="subform12513" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Block10"><div class="xfaLr"><div class="xfaWrapper" style="width: 192px; height: 14.4px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px 0px 1.42px 7.2px;" data-element-id="draw12514" class="xfaDraw xfaFont xfaWrapped" xfaname="AccountType10"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 12.96px; padding-top: 0px; padding-bottom: 0px; text-indent: -12.96px;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">10. ACCOUNT TYPE<span> </span><span style="font-size: 6.93px; font-weight: normal; font-style: italic;">(Check one)</span></p></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 16.56px; height: 14.4px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw12532" class="xfaDraw xfaFont xfaWrapped" xfaname="buffer"></div></div><div class="xfaWrapper" style="width: 72px; height: 14.4px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field12537" class="xfaField xfaFont xfaWrapped" xfaname="Checking" title="10. ACCOUNT TYPE (Check one) - Select for "account type - checking.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 53px;" class="xfaCaptionForCheckButton"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span>CHECKING</span></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field12537" type="checkbox" xfaon="1" xfaoff="0" aria-label="10. ACCOUNT TYPE (Check one) - Select for "account type - checking."" aria-required="false" tabindex="5000" value="0"></label></div></div><div class="xfaWrapper" style="width: 72px; height: 14.4px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field12566" class="xfaField xfaFont xfaWrapped" xfaname="Savings" title="10. ACCOUNT TYPE (Check one) - Select for "account type - savings.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 53px;" class="xfaCaptionForCheckButton"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span>SAVINGS </span></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field12566" type="checkbox" xfaon="1" xfaoff="0" aria-label="10. ACCOUNT TYPE (Check one) - Select for "account type - savings."" aria-required="false" tabindex="5000" value="0"></label></div></div></div></div></div><div class="xfaWrapper" style="width: 192px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field12602" class="xfaField xfaFont xfaWrapped" xfaname="RoutNo11" title="Enter routing number."><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 7.2px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">11. ROUTING NUMBER<span> </span><span style="font-size: 6.93px; font-weight: normal; font-style: italic;">(See Instructions)</span></p></div></div><input type="text" fieldid="field12602" class="xfaTextfield" style="height: 16.96px;" aria-label="Enter routing number." aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 192px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field12625" class="xfaField xfaFont xfaWrapped" xfaname="AcctNo12" title="Enter account number."><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 7.2px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">12. ACCOUNT NUMBER<span> </span><span style="font-size: 6.93px; font-weight: normal; font-style: italic; text-decoration: none;">(See Instructions)</span></p></div></div><input type="text" fieldid="field12625" class="xfaTextfield" style="height: 16.96px;" aria-label="Enter account number." aria-required="false" tabindex="5000"></label></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 41.41px; position: relative; align-self: start;"><div data-element-id="subform12648" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Block13"><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 12.61px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.248457px; left: -0.25px; width: calc(100% + 0.799921px); height: calc(100% + 0.798378px); border-width: 0.5px 1.1px 1.1px 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid solid none;"></div><div style="font-kerning: normal; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px 1.42px 1.42px 7.2px;" data-element-id="draw12649" class="xfaDraw xfaFont xfaWrapped" xfaname="Financial13" role="heading" aria-level="1"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>13. FINANCIAL INSTITUTION</span></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 144px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field12667" class="xfaField xfaFont xfaWrapped" xfaname="Name" title="13. FINANCIAL INSTITUTION - a. NAME"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 7.2px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>a. NAME</span></div></div><input type="text" fieldid="field12667" class="xfaTextfield" style="height: 16.96px;" aria-label="13. FINANCIAL INSTITUTION - a. NAME" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 216px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field12688" class="xfaField xfaFont xfaWrapped" xfaname="Street" title="13. FINANCIAL INSTITUTION - b. STREET (Include apartment number)"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 7.2px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">b. STREET<span> </span><span style="font-weight: normal; font-style: italic;">(Include apartment number)</span></p></div></div><input type="text" fieldid="field12688" class="xfaTextfield" style="height: 16.96px;" aria-label="13. FINANCIAL INSTITUTION - b. STREET (Include apartment number)" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 108px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field12709" class="xfaField xfaFont xfaWrapped" xfaname="City" title="13. FINANCIAL INSTITUTION - c. CITY"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 7.2px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>c. CITY</span></div></div><input type="text" fieldid="field12709" class="xfaTextfield" style="height: 16.96px;" aria-label="13. FINANCIAL INSTITUTION - c. CITY" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 46.8px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.358px); border-width: 0.5px 0.5px 0.22px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field12730" class="xfaField xfaFont xfaWrapped" xfaname="State" title="13. FINANCIAL INSTITUTION - d. STATE (select from drop-down list)"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 3.6px;"><span>d. STATE</span></div></div><select class="xfaSelect" fieldid="field12730" style="border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 15.96px;" aria-label="13. FINANCIAL INSTITUTION - d. STATE (select from drop-down list)" aria-required="false" tabindex="5000"><option selected="true" hidden="true"> </option><option value="AL" style="font-size: calc(10px * var(--scale-factor));">AL</option><option value="AK" style="font-size: calc(10px * var(--scale-factor));">AK</option><option value="AZ" style="font-size: calc(10px * var(--scale-factor));">AZ</option><option value="AR" style="font-size: calc(10px * var(--scale-factor));">AR</option><option value="CA" style="font-size: calc(10px * var(--scale-factor));">CA</option><option value="CO" style="font-size: calc(10px * var(--scale-factor));">CO</option><option value="CT" style="font-size: calc(10px * var(--scale-factor));">CT</option><option value="DE" style="font-size: calc(10px * var(--scale-factor));">DE</option><option value="DC" style="font-size: calc(10px * var(--scale-factor));">DC</option><option value="FL" style="font-size: calc(10px * var(--scale-factor));">FL</option><option value="GA" style="font-size: calc(10px * var(--scale-factor));">GA</option><option value="HI" style="font-size: calc(10px * var(--scale-factor));">HI</option><option value="ID" style="font-size: calc(10px * var(--scale-factor));">ID</option><option value="IL" style="font-size: calc(10px * var(--scale-factor));">IL</option><option value="IN" style="font-size: calc(10px * var(--scale-factor));">IN</option><option value="IA" style="font-size: calc(10px * var(--scale-factor));">IA</option><option value="KS" style="font-size: calc(10px * var(--scale-factor));">KS</option><option value="KY" style="font-size: calc(10px * var(--scale-factor));">KY</option><option value="LA" style="font-size: calc(10px * var(--scale-factor));">LA</option><option value="ME" style="font-size: calc(10px * var(--scale-factor));">ME</option><option value="MD" style="font-size: calc(10px * var(--scale-factor));">MD</option><option value="MA" style="font-size: calc(10px * var(--scale-factor));">MA</option><option value="MI" style="font-size: calc(10px * var(--scale-factor));">MI</option><option value="MN" style="font-size: calc(10px * var(--scale-factor));">MN</option><option value="MS" style="font-size: calc(10px * var(--scale-factor));">MS</option><option value="MO" style="font-size: calc(10px * var(--scale-factor));">MO</option><option value="MT" style="font-size: calc(10px * var(--scale-factor));">MT</option><option value="NE" style="font-size: calc(10px * var(--scale-factor));">NE</option><option value="NV" style="font-size: calc(10px * var(--scale-factor));">NV</option><option value="NH" style="font-size: calc(10px * var(--scale-factor));">NH</option><option value="NJ" style="font-size: calc(10px * var(--scale-factor));">NJ</option><option value="NM" style="font-size: calc(10px * var(--scale-factor));">NM</option><option value="NY" style="font-size: calc(10px * var(--scale-factor));">NY</option><option value="NC" style="font-size: calc(10px * var(--scale-factor));">NC</option><option value="ND" style="font-size: calc(10px * var(--scale-factor));">ND</option><option value="OH" style="font-size: calc(10px * var(--scale-factor));">OH</option><option value="OK" style="font-size: calc(10px * var(--scale-factor));">OK</option><option value="OR" style="font-size: calc(10px * var(--scale-factor));">OR</option><option value="PA" style="font-size: calc(10px * var(--scale-factor));">PA</option><option value="RI" style="font-size: calc(10px * var(--scale-factor));">RI</option><option value="SC" style="font-size: calc(10px * var(--scale-factor));">SC</option><option value="SD" style="font-size: calc(10px * var(--scale-factor));">SD</option><option value="TN" style="font-size: calc(10px * var(--scale-factor));">TN</option><option value="TX" style="font-size: calc(10px * var(--scale-factor));">TX</option><option value="UT" style="font-size: calc(10px * var(--scale-factor));">UT</option><option value="VT" style="font-size: calc(10px * var(--scale-factor));">VT</option><option value="VA" style="font-size: calc(10px * var(--scale-factor));">VA</option><option value="WA" style="font-size: calc(10px * var(--scale-factor));">WA</option><option value="WV" style="font-size: calc(10px * var(--scale-factor));">WV</option><option value="WI" style="font-size: calc(10px * var(--scale-factor));">WI</option><option value="WY" style="font-size: calc(10px * var(--scale-factor));">WY</option></select></label></div></div><div class="xfaWrapper" style="width: 61.2px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field12860" class="xfaField xfaFont xfaWrapped" xfaname="ZipCode" title="13. FINANCIAL INSTITUTION - e. ZIP CODE"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span> e. ZIP CODE</span></div></div><input type="text" fieldid="field12860" class="xfaTextfield" style="border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 15.96px;" aria-label="13. FINANCIAL INSTITUTION - e. ZIP CODE" aria-required="false" tabindex="5000"></label></div></div></div></div></div></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 138.75px; position: relative; align-self: start;"><div data-element-id="subform12900" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Section3Block"><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 14.4px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.500457px; left: -0.749055px; width: calc(100% + 1.49811px); height: calc(100% + 1.00091px); border-width: 1px 1.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: normal; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; background-color: rgb(192, 192, 192); padding: 1.42px 1.42px 1.42px 7.2px;" data-element-id="draw12901" class="xfaDraw xfaFont xfaWrapped" xfaname="Section3" role="heading" aria-level="1"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>SECTION III - SEPARATION PAYMENT INFORMATION</span></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 61.57px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div data-element-id="subform12921" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Block14"><div class="xfaLr"><div class="xfaWrapper" style="width: 457.2px; height: 47.17px; position: relative; align-self: start;"><div data-element-id="subform12925" class="xfaSubform xfaLrTb xfaWrapped" xfaname="PaymentType"><div class="xfaLr"><div class="xfaWrapper" style="width: 457.2px; height: 12.61px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px 1.42px 1.42px 0px;" data-element-id="draw12926" class="xfaDraw xfaFont xfaWrapped" xfaname="textTitle"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 7.2px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="letter-spacing: 0px;">14. a. PAYMENT TYPE RECEIVED<span> </span><span style="font-size: 6.93px; font-weight: normal; font-style: italic;">(Check one)</span></p></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 16.56px; height: 34.56px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw12944" class="xfaDraw xfaFont xfaWrapped" xfaname="buffer"></div></div><div class="xfaWrapper" style="width: 440.64px; height: 34.56px; position: relative; align-self: start;"><div data-element-id="subform12949" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Checklist"><div class="xfaLr"><div class="xfaWrapper" style="width: 59.04px; height: 17.28px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field12950" class="xfaField xfaFont xfaWrapped" xfaname="none" title="SECTION III - SEPARATION PAYMENT INFORMATION - 14. a. PAYMENT TYPE RECEIVED (Check one) - Select for "payment type received - NONE.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 40px;" class="xfaCaptionForCheckButton"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span>NONE</span></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field12950" type="checkbox" xfaon="1" xfaoff="0" aria-label="SECTION III - SEPARATION PAYMENT INFORMATION - 14. a. PAYMENT TYPE RECEIVED (Check one) - Select for "payment type received - NONE."" aria-required="false" tabindex="5000" value="0"></label></div></div><div class="xfaWrapper" style="width: 158.4px; height: 17.28px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field12979" class="xfaField xfaFont xfaWrapped" xfaname="a" title="14. a. PAYMENT TYPE RECEIVED (Check one) - Select for "payment type received - SEVERANCE PAY (SE).""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 139px;" class="xfaCaptionForCheckButton"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span>DISABILITY SEVERANCE PAY (DSP)</span></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field12979" type="checkbox" xfaon="1" xfaoff="0" aria-label="14. a. PAYMENT TYPE RECEIVED (Check one) - Select for "payment type received - SEVERANCE PAY (SE)."" aria-required="false" tabindex="5000" value="0"></label></div></div><div class="xfaWrapper" style="width: 223.2px; height: 17.28px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field13037" class="xfaField xfaFont xfaWrapped" xfaname="c" title="14. a. PAYMENT TYPE RECEIVED (Check one) - Select for "payment type received - SEPARATION PAY (SP).""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 204px;" class="xfaCaptionForCheckButton"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span>INVOLUNTARY / VOLUNTARY SEPARATION PAY (SP)</span></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field13037" type="checkbox" xfaon="1" xfaoff="0" aria-label="14. a. PAYMENT TYPE RECEIVED (Check one) - Select for "payment type received - SEPARATION PAY (SP)."" aria-required="false" tabindex="5000" value="0"></label></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 217.44px; height: 17.28px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field13066" class="xfaField xfaFont xfaWrapped" xfaname="d" title="14. a. PAYMENT TYPE RECEIVED (Check one) - Select for "payment type received - VOLUNTARY SEPARATION INCENTIVE (VSI).""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 198px;" class="xfaCaptionForCheckButton"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span>VOLUNTARY SEPARATION INCENTIVE (VSI)</span></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field13066" type="checkbox" xfaon="1" xfaoff="0" aria-label="14. a. PAYMENT TYPE RECEIVED (Check one) - Select for "payment type received - VOLUNTARY SEPARATION INCENTIVE (VSI)."" aria-required="false" tabindex="5000" value="0"></label></div></div><div class="xfaWrapper" style="width: 172.8px; height: 17.28px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field13095" class="xfaField xfaFont xfaWrapped" xfaname="e" title="14. a. PAYMENT TYPE RECEIVED (Check one) - Select for "payment type received - SPECIAL SEPARATION BONUS (SSB).""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 153px;" class="xfaCaptionForCheckButton"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span>SPECIAL SEPARATION BONUS (SSB)</span></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field13095" type="checkbox" xfaon="1" xfaoff="0" aria-label="14. a. PAYMENT TYPE RECEIVED (Check one) - Select for "payment type received - SPECIAL SEPARATION BONUS (SSB)."" aria-required="false" tabindex="5000" value="0"></label></div></div><div class="xfaWrapper" style="width: 50.4px; height: 17.28px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field13124" class="xfaField xfaFont xfaWrapped" xfaname="f" title="14. a. PAYMENT TYPE RECEIVED (Check one) - Select for "payment type received - OTHER.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 31px;" class="xfaCaptionForCheckButton"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span>OTHER</span></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field13124" type="checkbox" xfaon="1" xfaoff="0" aria-label="14. a. PAYMENT TYPE RECEIVED (Check one) - Select for "payment type received - OTHER."" aria-required="false" tabindex="5000" value="0"></label></div></div></div></div></div></div></div></div><div class="xfaWrapper" style="width: 118.8px; height: 47.17px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field13161" class="xfaField xfaFont xfaWrapped" xfaname="GrossAmt" title="14.b. GROSS AMOUNT"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 7.2px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>b. GROSS AMOUNT</span></div></div><input type="text" fieldid="field13161" class="xfaTextfield" style="height: 35.33px;" aria-label="14.b. GROSS AMOUNT" aria-required="false" tabindex="5000"></label></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 14.4px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw13189" class="xfaDraw xfaFont xfaWrapped" xfaname="Note"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 16.56px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="font-weight: normal; text-decoration: none; letter-spacing: 0px;">NOTE: If any payment type was selected, attach a<span style="font-weight: bold;"> COPY OF THE ORDERS<span> </span></span>which authorized the payment and a<span style="font-weight: bold;"> COPY OF THE DD FORM 214</span>.</p></div></div></div></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 62.78px; position: relative; align-self: start;"><div data-element-id="subform13205" class="xfaSubform xfaLrTb xfaWrapped" xfaname="FileAttachments"><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 48.38px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field13206" class="xfaField xfaFont xfaWrapped" xfaname="attachmentsList" title="List of attachments."><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span> List Of Attachments</span></div></div><select class="xfaSelect" fieldid="field13206" style="border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 35.55px;" aria-label="List of attachments." aria-required="false" multiple="true" tabindex="5000"></select></label></div></div></div><div class="xfaLr"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; width: 115.2px; height: 14.4px; align-self: start;" data-element-id="field13230" class="xfaField xfaFont" xfaname="AddAttachment" title="Click on this button to attach a file(s)."><button data-element-id="button13232" class="xfaButton" style="background-color: rgb(212, 208, 200); border-style: outset; border-width: 0.5px; border-color: rgb(0, 0, 0);" tabindex="5000"><span style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 58.06px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: center; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>Add Attachment</span></div></span></button></div><div class="xfaWrapper" style="width: 38.38px; height: 14.4px; position: relative; align-self: start;"><div data-element-id="draw13253" class="xfaDraw xfaWrapped" xfaname="spacer1"><svg xmlns="http://www.w3.org/2000/svg" style="overflow: visible; position: absolute;" width="100%" height="100%"><rect xmlns="http://www.w3.org/2000/svg" width="100%" height="100%" x="0" y="0" rx="0px" ry="0px" style="fill: transparent; stroke-width: 0px; stroke: rgb(0, 0, 0);"></rect></svg></div></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; width: 115.2px; height: 14.4px; align-self: start;" data-element-id="field13258" class="xfaField xfaFont" xfaname="OpenAttachment" title="Click on this button to open a file(s)."><button data-element-id="button13260" class="xfaButton" style="background-color: rgb(212, 208, 200); border-style: outset; border-width: 0.5px; border-color: rgb(0, 0, 0);" tabindex="5000"><span style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 97.52px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: center; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>Open Selected Attachment</span></div></span></button></div><div class="xfaWrapper" style="width: 38.38px; height: 14.4px; position: relative; align-self: start;"><div data-element-id="draw13281" class="xfaDraw xfaWrapped" xfaname="spacer2"><svg xmlns="http://www.w3.org/2000/svg" style="overflow: visible; position: absolute;" width="100%" height="100%"><rect xmlns="http://www.w3.org/2000/svg" width="100%" height="100%" x="0" y="0" rx="0px" ry="0px" style="fill: transparent; stroke-width: 0px; stroke: rgb(0, 0, 0);"></rect></svg></div></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; width: 115.2px; height: 14.4px; align-self: start;" data-element-id="field13286" class="xfaField xfaFont" xfaname="RemoveAttachment" title="Click on this button to remove a file(s)."><button data-element-id="button13288" class="xfaButton" style="background-color: rgb(212, 208, 200); border-style: outset; border-width: 0.5px; border-color: rgb(0, 0, 0);" tabindex="5000"><span style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 107.94px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: center; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>Remove Selected Attachment</span></div></span></button></div><div class="xfaWrapper" style="width: 38.38px; height: 14.4px; position: relative; align-self: start;"><div data-element-id="draw13309" class="xfaDraw xfaWrapped" xfaname="spacer3"><svg xmlns="http://www.w3.org/2000/svg" style="overflow: visible; position: absolute;" width="100%" height="100%"><rect xmlns="http://www.w3.org/2000/svg" width="100%" height="100%" x="0" y="0" rx="0px" ry="0px" style="fill: transparent; stroke-width: 0px; stroke: rgb(0, 0, 0);"></rect></svg></div></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; width: 115.2px; height: 14.4px; align-self: start;" data-element-id="field13314" class="xfaField xfaFont" xfaname="ShowAttachment" title="Click on this button to show the attachment bar."><button data-element-id="button13316" class="xfaButton" style="background-color: rgb(212, 208, 200); border-style: outset; border-width: 0.5px; border-color: rgb(0, 0, 0);" tabindex="5000"><span style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 78.92px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: center; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>Show Attachment Bar</span></div></span></button></div></div></div></div></div></div></div></div></div></div></div></div></div></div><div class="annotationLayer" hidden=""></div></div><div class="page" data-page-number="2" role="region" style="width: calc(var(--scale-factor) * 612px); height: calc(var(--scale-factor) * 792px);" aria-label="Page 2" data-loaded="true"><div class="canvasWrapper"><canvas role="presentation" style="width: 1020px; height: 1320px;" width="1020" height="1320"></canvas></div><div style="transform: matrix(1.66667, 0, 0, 1.66667, 0, 0);" class="xfaLayer xfaFont"><div class="xfaPage" data-element-id="pageArea10544" style="width: 612px; height: 792px;" xfaname="Page1"><div class="xfaWrapper" style="top: 25.2px; left: 18px; width: 576px; height: 730.8px; position: absolute; align-self: start;"><div data-element-id="draw10547" class="xfaDraw xfaWrapped" xfaname="Frame"><svg xmlns="http://www.w3.org/2000/svg" style="overflow: visible; position: absolute;" width="100%" height="100%"><rect xmlns="http://www.w3.org/2000/svg" width="100%" height="100%" x="0" y="0" rx="0px" ry="0px" style="fill: transparent; stroke-width: 1.5px; stroke: rgb(0, 0, 0);"></rect></svg></div></div><div class="xfaWrapper" style="top: 756px; left: 532.37px; width: 61.63px; height: 12px; position: absolute; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 0px;" data-element-id="draw10590" class="xfaDraw xfaFont xfaWrapped" xfaname="Pages"><div style="display: flex; flex-direction: column; justify-content: center; text-align: right; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p>Page<span> </span> of<span> </span></p></div></div></div><div class="xfaWrapper" style="top: 756px; left: 18.39px; width: 184.5px; height: 12px; position: absolute; align-self: start;"><div class="xfaBorder" style="top: -0.288px; left: -0.288px; width: calc(100% + 0.576px); height: calc(100% + 0.576px); border-width: 0.58px; border-color: rgb(0, 0, 0); border-style: none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 0px 3.6px;" data-element-id="draw10599" class="xfaDraw xfaFont xfaWrapped" xfaname="FormNumber_Date"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: end; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>DD FORM 2656, MARCH 2022</span></div></div></div><div class="xfaWrapper" style="top: 10.44px; left: 223.2px; width: 368.4px; height: 781.56px; position: absolute; align-self: start;"><div data-element-id="subform10613" class="xfaSubform xfaPosition xfaWrapped"><div class="xfaWrapper" style="top: 759.96px; left: 0px; width: 165.6px; height: 12.24px; position: absolute; align-self: start;"><div class="xfaBorder" style="top: -0.288px; left: -0.288px; width: calc(100% + 0.576px); height: calc(100% + 0.576px); border-width: 0.58px; border-color: rgb(0, 0, 0); border-style: none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 0px 3.6px;" data-element-id="draw10615" class="xfaDraw xfaFont xfaWrapped" xfaname="SecessionNotice"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: end; text-align: center; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>PREVIOUS EDITION IS OBSOLETE.</span></div></div></div><div class="xfaWrapper" style="top: 745.56px; left: 28.8px; width: 108px; height: 14.4px; position: absolute; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 0px;" data-element-id="draw10629" class="xfaDraw xfaFont xfaWrapped" xfaname="CUIfooter" title="Document classification when filled in is CUI"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="text-align: center; text-decoration: none; letter-spacing: 0px;">CUI (when filled in)</p></div></div></div><div class="xfaWrapper" style="top: 0px; left: 28.8px; width: 108px; height: 14.4px; position: absolute; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 0px;" data-element-id="draw10640" class="xfaDraw xfaFont xfaWrapped" xfaname="CUIheader" title="Document classification when filled in is CUI"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="text-align: center; text-decoration: none; letter-spacing: 0px;">CUI (when filled in)</p></div></div></div><div class="xfaWrapper" style="top: 747.72px; left: 206.64px; width: 161.76px; height: 33.84px; position: absolute; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 6.43px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 0px;" data-element-id="draw10651" class="xfaDraw xfaFont xfaWrapped" xfaname="CUIField"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><p><span>Controlled by: OUSD(P&R)</span><br></p><p><span>CUI Category: PRVCY</span><br></p><p><span>LDC: FEDCON</span><br></p><p><span>POC: osd.pentagon.ousd-p-r.mbx.forms@mail.mil</span><br></p></div></div></div></div></div><div style="left: 18px; top: 25.2px; width: 576px; height: 730.8px;" class="xfaContentarea" data-element-id="contentArea10545"><div data-element-id="subform10542" class="xfaSubform xfaTb" style="width: auto; height: auto; position: absolute; left: 0px; top: 0px; align-self: start;" xfaname="form1"><div class="xfaWrapper" style="width: 576px; height: 701.83px; position: relative; align-self: start;"><div data-element-id="subform13369" class="xfaSubform xfaLrTb xfaWrapped" xfaname="page2"><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 105.12px; position: relative; align-self: start;"><div data-element-id="subform13371" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Section4Block"><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 21.6px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.500457px; left: -0.500457px; width: calc(100% + 1.00091px); height: calc(100% + 1.00091px); border-width: 1px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: normal; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; background-color: rgb(192, 192, 192); padding: 1.42px 1.42px 1.42px 7.2px;" data-element-id="draw13373" class="xfaDraw xfaFont xfaWrapped" xfaname="Section4" role="heading" aria-level="1"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>SECTION IV - DEPARTMENT OF VETERANS AFFAIRS (VA) DISABILITY COMPENSATION INFORMATION</span></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 83.52px; position: relative; align-self: start;"><div data-element-id="subform13387" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Block15"><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 18.72px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 0px;" data-element-id="draw13388" class="xfaDraw xfaFont xfaWrapped" xfaname="textTitle"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 7.2px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>15. VA DISABILITY COMPENSATION</span></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 206.64px; height: 64.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div data-element-id="subform13406" class="xfaSubform xfaPosition xfaWrapped" xfaname="NotifyDFAS"><div class="xfaWrapper" style="top: 0px; left: 0px; width: 206.64px; height: 64.8px; position: absolute; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.44px 0px 1.42px;" data-element-id="draw13407" class="xfaDraw xfaFont xfaWrapped" xfaname="NotifyDFAS"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: start; text-align: left; padding-left: 15.84px; padding-top: 0px; padding-bottom: 0px; text-indent: -8.64px;"><span>a. IN THE EVENT I AM AWARDED DISABILITY COMPENSATION BY THE VA, I WILL NOTIFY DFAS (OR THE COAST GUARD PPC FOR NON-DOD MEMBERS) OF THE AMOUNT OF ANY AWARD, AS IT MAY IMPACT MY RETIRED PAY BENEFIT.</span></div></div></div><div class="xfaWrapper" style="top: 48.72px; left: 64.25px; width: 72px; height: 14.4px; position: absolute; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field13415" class="xfaField xfaFont xfaWrapped" xfaname="Agree" title="SECTION IV - DEPARTMENT OF VETERANS AFFAIRS (VA) DISABILITY COMPENSATION INFORMATION - 15. VA DISABILITY COMPENSATION - a. IN THE EVENT I AM AWARDED DISABILITY COMPENSATION BY THE VA, I WILL NOTIFY DFAS (OR THE COAST GUARD PPC FOR NON-DOD MEMBERS) OF THE AMOUNT OF ANY AWARD, AS IT MAY IMPACT MY RETIRED PAY BENEFIT. - Select for "agree.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 53px;" class="xfaCaptionForCheckButton"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span>Agree</span></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field13415" type="checkbox" xfaon="1" xfaoff="0" aria-label="SECTION IV - DEPARTMENT OF VETERANS AFFAIRS (VA) DISABILITY COMPENSATION INFORMATION - 15. VA DISABILITY COMPENSATION - a. IN THE EVENT I AM AWARDED DISABILITY COMPENSATION BY THE VA, I WILL NOTIFY DFAS (OR THE COAST GUARD PPC FOR NON-DOD MEMBERS) OF THE AMOUNT OF ANY AWARD, AS IT MAY IMPACT MY RETIRED PAY BENEFIT. - Select for "agree."" aria-required="false" tabindex="5000" value="0"></label></div></div></div></div><div class="xfaWrapper" style="width: 169.92px; height: 64.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div data-element-id="subform13443" class="xfaSubform xfaLrTb xfaWrapped" xfaname="VACompensation"><div class="xfaLr"><div class="xfaWrapper" style="width: 169.92px; height: 32.4px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.44px 1.42px 1.42px;" data-element-id="draw13444" class="xfaDraw xfaFont xfaWrapped" xfaname="textTitle"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: start; text-align: left; padding-left: 15.84px; padding-top: 0px; padding-bottom: 0px; text-indent: -8.64px;"><span>b. HAVE YOU APPLIED FOR OR ARE YOU RECEIVING VA COMPENSATION FOR A DISABILITY? </span></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 16.56px; height: 14.4px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw13452" class="xfaDraw xfaFont xfaWrapped" xfaname="buffer"></div></div><div class="xfaWrapper" style="width: 72px; height: 32.4px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field13457" class="xfaField xfaFont xfaWrapped" xfaname="Yes" title="15. VA DISABILITY COMPENSATION - b. HAVE YOU APPLIED FOR OR ARE YOU RECEIVING VA COMPENSATION FOR A DISABILITY? - Select for "yes.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 53px;" class="xfaCaptionForCheckButton"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span>Yes</span></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field13457" type="checkbox" xfaon="1" xfaoff="0" aria-label="15. VA DISABILITY COMPENSATION - b. HAVE YOU APPLIED FOR OR ARE YOU RECEIVING VA COMPENSATION FOR A DISABILITY? - Select for "yes."" aria-required="false" tabindex="5000" value="0"></label></div></div><div class="xfaWrapper" style="width: 72px; height: 32.4px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field13482" class="xfaField xfaFont xfaWrapped" xfaname="No" title="15. VA DISABILITY COMPENSATION - b. HAVE YOU APPLIED FOR OR ARE YOU RECEIVING VA COMPENSATION FOR A DISABILITY? - Select for "no.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 53px;" class="xfaCaptionForCheckButton"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left;"><span>No</span></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field13482" type="checkbox" xfaon="1" xfaoff="0" aria-label="15. VA DISABILITY COMPENSATION - b. HAVE YOU APPLIED FOR OR ARE YOU RECEIVING VA COMPENSATION FOR A DISABILITY? - Select for "no."" aria-required="false" tabindex="5000" value="0"></label></div></div></div></div></div><div class="xfaWrapper" style="width: 104.4px; height: 64.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field13511" class="xfaField xfaFont xfaWrapped" xfaname="PaymentDate" title="15. VA DISABILITY COMPENSATION - c. EFFECTIVE DATE OF PAYMENT (YYYYMMDD)"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 18px;" class="xfaCaption"><div style="display: flex; flex-direction: column; justify-content: start; text-align: left; padding-left: 8.64px; padding-top: 0px; padding-bottom: 0px; text-indent: -8.64px;" class="xfaRich"><p style="text-indent: -8.64px; text-decoration: none; letter-spacing: 0px; padding-left: 8.64px;">c. EFFECTIVE DATE OF PAYMENT<span> </span><span style="font-size: 6.93px; font-weight: normal; font-style: italic;">(YYYYMMDD)</span></p></div></div><input type="text" fieldid="field13511" class="xfaTextfield" style="height: 43.96px;" aria-label="15. VA DISABILITY COMPENSATION - c. EFFECTIVE DATE OF PAYMENT (YYYYMMDD)" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 95.04px; height: 64.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field13537" class="xfaField xfaFont xfaWrapped" xfaname="MonthlyPaymnt" title="15. VA DISABILITY COMPENSATION - d. MONTHLY AMOUNT OF PAYMENT"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 18px;" class="xfaCaption"><div style="display: flex; flex-direction: column; justify-content: start; text-align: left; padding-left: 8.64px; padding-top: 0px; padding-bottom: 0px; text-indent: -8.64px;" class="xfaRich"><p style="text-indent: -8.64px; text-decoration: none; letter-spacing: 0px; padding-left: 8.64px;">d. MONTHLY AMOUNT OF PAYMENT</p></div></div><input type="text" fieldid="field13537" class="xfaTextfield" style="height: 43.96px;" aria-label="15. VA DISABILITY COMPENSATION - d. MONTHLY AMOUNT OF PAYMENT" aria-required="false" tabindex="5000"></label></div></div></div></div></div></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 200.59px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.749055px; left: -0.500457px; width: calc(100% + 1.00091px); height: calc(100% + 1.49811px); border-width: 1.5px 1px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div data-element-id="subform13562" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Section5Block"><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 21.6px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.500457px; left: -0.500457px; width: calc(100% + 1.00091px); height: calc(100% + 1.00091px); border-width: 1px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: normal; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; background-color: rgb(192, 192, 192); padding: 1.42px 1.42px 1.42px 7.2px;" data-element-id="draw13563" class="xfaDraw xfaFont xfaWrapped" xfaname="Section5" role="heading" aria-level="1"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="letter-spacing: 0px;">SECTION V - DESIGNATION OF BENEFICIARIES FOR UNPAID RETIRED PAY<span> </span><span style="font-weight: normal; font-style: italic;">(See Instructions)</span></p></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 178.99px; position: relative; align-self: start;"><div data-element-id="subform13577" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Block16"><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 17.28px; position: relative; align-self: start;"><div data-element-id="subform13578" class="xfaSubform xfaLrTb xfaWrapped" xfaname="DesigSpouse"><div class="xfaLr"><div class="xfaWrapper" style="width: 16.56px; height: 17.28px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw13579" class="xfaDraw xfaFont xfaWrapped" xfaname="buffer"></div></div><div class="xfaWrapper" style="width: 559.44px; height: 17.28px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: none none solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field13584" class="xfaField xfaFont xfaWrapped" xfaname="Spouse100Ben" title="SECTION V - DESIGNATION OF BENEFICIARIES FOR UNPAID RETIRED PAY (See Instructions) - Check this box if you want to designate your spouse as 100% beneficiary of any unpaid retired pay upon death OR complete Item 16."><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 540px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left;" class="xfaRich"><p style="letter-spacing: 0px;">Check this box if you want to designate your spouse as 100% beneficiary of any unpaid retired pay upon death<span> </span><span style="font-weight: bold; text-decoration: underline;">OR</span> complete Item 16.</p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field13584" type="checkbox" xfaon="1" xfaoff="0" aria-label="SECTION V - DESIGNATION OF BENEFICIARIES FOR UNPAID RETIRED PAY (See Instructions) - Check this box if you want to designate your spouse as 100% beneficiary of any unpaid retired pay upon death OR complete Item 16." aria-required="false" tabindex="5000" value="0"></label></div></div></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 161.71px; position: relative; align-self: start;"><div data-element-id="subform13615" class="xfaSubform xfaLrTb xfaWrapped" xfaname="BeneficInfo"><div class="xfaLr"><div class="xfaWrapper" style="width: 414px; height: 14.4px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none none solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 0px;" data-element-id="draw13616" class="xfaDraw xfaFont xfaWrapped" xfaname="BeneficInfo"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 7.2px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>16. BENEFICIARY OR BENEFICIARIES INFORMATION</span></div></div></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; width: 81px; height: 14.4px; align-self: start;" data-element-id="field13634" class="xfaField xfaFont" xfaname="addrow" title="16. BENEFICIARY OR BENEFICIARIES INFORMATION - Select to add a row to beneficiar(ies) information."><button data-element-id="button13636" class="xfaButton" style="background-color: rgb(212, 208, 200); border-style: outset; border-width: 0.5px; border-color: rgb(0, 0, 0);" tabindex="5000"><span style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 33.11px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: center;"><span>Add Row</span></div></span></button></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; width: 81px; height: 14.4px; align-self: start;" data-element-id="field13653" class="xfaField xfaFont" xfaname="Removerow" title="16. BENEFICIARY OR BENEFICIARIES INFORMATION - Select to remove last row from beneficiar(ies) information."><button data-element-id="button13655" class="xfaButton" style="background-color: rgb(212, 208, 200); border-style: outset; border-width: 0.5px; border-color: rgb(0, 0, 0);" tabindex="5000"><span style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 66.66px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: center;"><span>Remove Last Row</span></div></span></button></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 24.48px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: none solid solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw13672" class="xfaDraw xfaFont xfaWrapped" xfaname="Note"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 16.56px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="font-weight: normal; text-decoration: none; letter-spacing: 0px;">Complete this section if you want to designate a beneficiary or beneficiaries to receive any unpaid retired pay you are due at death.<span> </span></p><p style="font-weight: normal; text-decoration: none; letter-spacing: 0px;">If you do not complete this section<span> </span><span style="font-weight: bold; text-decoration: underline;">OR</span> check the box above, your unpaid retired pay will be distributed to beneficiaries in accordance with 10 U.S.C. §2771.</p></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 144px; height: 14.83px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw13690" class="xfaDraw xfaFont xfaWrapped" xfaname="NameTitle"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 12.96px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">a. NAME<span> </span><span style="font-size: 6.93px; font-weight: normal; font-style: italic;">(Last, First, Middle Initial)</span></p></div></div></div><div class="xfaWrapper" style="width: 79.2px; height: 14.83px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw13701" class="xfaDraw xfaFont xfaWrapped" xfaname="SSNTitle"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px;"><span>b. SSN</span></div></div></div><div class="xfaWrapper" style="width: 212.4px; height: 14.83px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw13712" class="xfaDraw xfaFont xfaWrapped" xfaname="AddressTitle"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px;" class="xfaRich"><p style="letter-spacing: 0px;">c. ADDRESS<span> </span><span style="font-size: 6.93px; font-weight: normal; font-style: italic;">(Street, City, State, ZIP Code)</span><span> </span></p></div></div></div><div class="xfaWrapper" style="width: 82.8px; height: 14.83px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw13723" class="xfaDraw xfaFont xfaWrapped" xfaname="RelationshipTitle"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px;"><span>d. RELATIONSHIP </span></div></div></div><div class="xfaWrapper" style="width: 57.6px; height: 14.83px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw13734" class="xfaDraw xfaFont xfaWrapped" xfaname="ShareTitle"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px;"><span>e. SHARE</span></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 18px; position: relative; align-self: start;"><div data-element-id="subform13745" class="xfaSubform xfaLrTb xfaWrapped" xfaname="NameSSNAddRelShare1"><div class="xfaLr"><div class="xfaWrapper" style="width: 14.4px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 1.42px 0.72px 1.42px 1.42px;" data-element-id="field13746" class="xfaField xfaFont xfaDisabled xfaWrapped" xfaname="rowCount"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field13746" class="xfaTextfield" style="border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 100%;" aria-required="false" tabindex="5000" value="1)"></label></div></div><div class="xfaWrapper" style="width: 129.6px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field13769" class="xfaField xfaFont xfaWrapped" xfaname="Name" title="16. BENEFICIARY OR BENEFICIARIES INFORMATION - a. NAME (Last, First, Middle Initial), new row"><label class="xfaLabel xfaLeft"><textarea fieldid="field13769" class="xfaTextfield" style="height: 100%;" aria-label="16. BENEFICIARY OR BENEFICIARIES INFORMATION - a. NAME (Last, First, Middle Initial), new row" aria-required="false" tabindex="5000"></textarea></label></div></div><div class="xfaWrapper" style="width: 79.2px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.248457px; left: -0.248457px; width: calc(100% + 0.496913px); height: calc(100% + 0.496913px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field13788" class="xfaField xfaFont xfaWrapped" xfaname="SSN" title="b. Social security number. Do not include dashes."><label class="xfaLabel xfaLeft"><input type="text" fieldid="field13788" class="xfaTextfield" style="height: 100%;" aria-label="b. Social security number. Do not include dashes." aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 212.4px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field13810" class="xfaField xfaFont xfaWrapped" xfaname="Address" title="c. ADDRESS (Street, City, State, ZIP Code)"><label class="xfaLabel xfaLeft"><textarea fieldid="field13810" class="xfaTextfield" style="height: 100%;" aria-label="c. ADDRESS (Street, City, State, ZIP Code)" aria-required="false" tabindex="5000"></textarea></label></div></div><div class="xfaWrapper" style="width: 82.8px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field13822" class="xfaField xfaFont xfaWrapped" xfaname="Rel" title="d. RELATIONSHIP"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field13822" class="xfaTextfield" style="height: 100%;" aria-label="d. RELATIONSHIP" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 45.36px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none solid solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field13834" class="xfaField xfaFont xfaWrapped" xfaname="Share" title="e. SHARE (percentage)"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field13834" class="xfaTextfield" style="height: 100%;" aria-label="e. SHARE (percentage)" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 12.24px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw13854" class="xfaDraw xfaFont xfaWrapped" xfaname="PercentSign"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px;"><span>%</span></div></div></div></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 18px; position: relative; align-self: start;"><div data-element-id="subform19337" class="xfaSubform xfaLrTb xfaWrapped" xfaname="NameSSNAddRelShare1"><div class="xfaLr"><div class="xfaWrapper" style="width: 14.4px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 1.42px 0.72px 1.42px 1.42px;" data-element-id="field19338" class="xfaField xfaFont xfaDisabled xfaWrapped" xfaname="rowCount"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19338" class="xfaTextfield" style="border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 100%;" aria-required="false" tabindex="5000" value="2)"></label></div></div><div class="xfaWrapper" style="width: 129.6px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19361" class="xfaField xfaFont xfaWrapped" xfaname="Name" title="16. BENEFICIARY OR BENEFICIARIES INFORMATION - a. NAME (Last, First, Middle Initial), new row"><label class="xfaLabel xfaLeft"><textarea fieldid="field19361" class="xfaTextfield" style="height: 100%;" aria-label="16. BENEFICIARY OR BENEFICIARIES INFORMATION - a. NAME (Last, First, Middle Initial), new row" aria-required="false" tabindex="5000"></textarea></label></div></div><div class="xfaWrapper" style="width: 79.2px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.248457px; left: -0.248457px; width: calc(100% + 0.496913px); height: calc(100% + 0.496913px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19379" class="xfaField xfaFont xfaWrapped" xfaname="SSN" title="b. Social security number. Do not include dashes."><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19379" class="xfaTextfield" style="height: 100%;" aria-label="b. Social security number. Do not include dashes." aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 212.4px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19401" class="xfaField xfaFont xfaWrapped" xfaname="Address" title="c. ADDRESS (Street, City, State, ZIP Code)"><label class="xfaLabel xfaLeft"><textarea fieldid="field19401" class="xfaTextfield" style="height: 100%;" aria-label="c. ADDRESS (Street, City, State, ZIP Code)" aria-required="false" tabindex="5000"></textarea></label></div></div><div class="xfaWrapper" style="width: 82.8px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19413" class="xfaField xfaFont xfaWrapped" xfaname="Rel" title="d. RELATIONSHIP"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19413" class="xfaTextfield" style="height: 100%;" aria-label="d. RELATIONSHIP" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 45.36px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none solid solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19425" class="xfaField xfaFont xfaWrapped" xfaname="Share" title="e. SHARE (percentage)"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19425" class="xfaTextfield" style="height: 100%;" aria-label="e. SHARE (percentage)" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 12.24px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw19445" class="xfaDraw xfaFont xfaWrapped" xfaname="PercentSign"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px;"><span>%</span></div></div></div></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 18px; position: relative; align-self: start;"><div data-element-id="subform19471" class="xfaSubform xfaLrTb xfaWrapped" xfaname="NameSSNAddRelShare1"><div class="xfaLr"><div class="xfaWrapper" style="width: 14.4px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 1.42px 0.72px 1.42px 1.42px;" data-element-id="field19472" class="xfaField xfaFont xfaDisabled xfaWrapped" xfaname="rowCount"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19472" class="xfaTextfield" style="border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 100%;" aria-required="false" tabindex="5000" value="3)"></label></div></div><div class="xfaWrapper" style="width: 129.6px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19495" class="xfaField xfaFont xfaWrapped" xfaname="Name" title="16. BENEFICIARY OR BENEFICIARIES INFORMATION - a. NAME (Last, First, Middle Initial), new row"><label class="xfaLabel xfaLeft"><textarea fieldid="field19495" class="xfaTextfield" style="height: 100%;" aria-label="16. BENEFICIARY OR BENEFICIARIES INFORMATION - a. NAME (Last, First, Middle Initial), new row" aria-required="false" tabindex="5000"></textarea></label></div></div><div class="xfaWrapper" style="width: 79.2px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.248457px; left: -0.248457px; width: calc(100% + 0.496913px); height: calc(100% + 0.496913px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19513" class="xfaField xfaFont xfaWrapped" xfaname="SSN" title="b. Social security number. Do not include dashes."><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19513" class="xfaTextfield" style="height: 100%;" aria-label="b. Social security number. Do not include dashes." aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 212.4px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19535" class="xfaField xfaFont xfaWrapped" xfaname="Address" title="c. ADDRESS (Street, City, State, ZIP Code)"><label class="xfaLabel xfaLeft"><textarea fieldid="field19535" class="xfaTextfield" style="height: 100%;" aria-label="c. ADDRESS (Street, City, State, ZIP Code)" aria-required="false" tabindex="5000"></textarea></label></div></div><div class="xfaWrapper" style="width: 82.8px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19547" class="xfaField xfaFont xfaWrapped" xfaname="Rel" title="d. RELATIONSHIP"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19547" class="xfaTextfield" style="height: 100%;" aria-label="d. RELATIONSHIP" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 45.36px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none solid solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19559" class="xfaField xfaFont xfaWrapped" xfaname="Share" title="e. SHARE (percentage)"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19559" class="xfaTextfield" style="height: 100%;" aria-label="e. SHARE (percentage)" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 12.24px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw19579" class="xfaDraw xfaFont xfaWrapped" xfaname="PercentSign"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px;"><span>%</span></div></div></div></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 18px; position: relative; align-self: start;"><div data-element-id="subform19605" class="xfaSubform xfaLrTb xfaWrapped" xfaname="NameSSNAddRelShare1"><div class="xfaLr"><div class="xfaWrapper" style="width: 14.4px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 1.42px 0.72px 1.42px 1.42px;" data-element-id="field19606" class="xfaField xfaFont xfaDisabled xfaWrapped" xfaname="rowCount"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19606" class="xfaTextfield" style="border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 100%;" aria-required="false" tabindex="5000" value="4)"></label></div></div><div class="xfaWrapper" style="width: 129.6px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19629" class="xfaField xfaFont xfaWrapped" xfaname="Name" title="16. BENEFICIARY OR BENEFICIARIES INFORMATION - a. NAME (Last, First, Middle Initial), new row"><label class="xfaLabel xfaLeft"><textarea fieldid="field19629" class="xfaTextfield" style="height: 100%;" aria-label="16. BENEFICIARY OR BENEFICIARIES INFORMATION - a. NAME (Last, First, Middle Initial), new row" aria-required="false" tabindex="5000"></textarea></label></div></div><div class="xfaWrapper" style="width: 79.2px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.248457px; left: -0.248457px; width: calc(100% + 0.496913px); height: calc(100% + 0.496913px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19647" class="xfaField xfaFont xfaWrapped" xfaname="SSN" title="b. Social security number. Do not include dashes."><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19647" class="xfaTextfield" style="height: 100%;" aria-label="b. Social security number. Do not include dashes." aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 212.4px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19669" class="xfaField xfaFont xfaWrapped" xfaname="Address" title="c. ADDRESS (Street, City, State, ZIP Code)"><label class="xfaLabel xfaLeft"><textarea fieldid="field19669" class="xfaTextfield" style="height: 100%;" aria-label="c. ADDRESS (Street, City, State, ZIP Code)" aria-required="false" tabindex="5000"></textarea></label></div></div><div class="xfaWrapper" style="width: 82.8px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19681" class="xfaField xfaFont xfaWrapped" xfaname="Rel" title="d. RELATIONSHIP"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19681" class="xfaTextfield" style="height: 100%;" aria-label="d. RELATIONSHIP" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 45.36px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none solid solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19693" class="xfaField xfaFont xfaWrapped" xfaname="Share" title="e. SHARE (percentage)"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19693" class="xfaTextfield" style="height: 100%;" aria-label="e. SHARE (percentage)" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 12.24px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw19713" class="xfaDraw xfaFont xfaWrapped" xfaname="PercentSign"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px;"><span>%</span></div></div></div></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 18px; position: relative; align-self: start;"><div data-element-id="subform19739" class="xfaSubform xfaLrTb xfaWrapped" xfaname="NameSSNAddRelShare1"><div class="xfaLr"><div class="xfaWrapper" style="width: 14.4px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 1.42px 0.72px 1.42px 1.42px;" data-element-id="field19740" class="xfaField xfaFont xfaDisabled xfaWrapped" xfaname="rowCount"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19740" class="xfaTextfield" style="border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 100%;" aria-required="false" tabindex="5000" value="5)"></label></div></div><div class="xfaWrapper" style="width: 129.6px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19763" class="xfaField xfaFont xfaWrapped" xfaname="Name" title="16. BENEFICIARY OR BENEFICIARIES INFORMATION - a. NAME (Last, First, Middle Initial), new row"><label class="xfaLabel xfaLeft"><textarea fieldid="field19763" class="xfaTextfield" style="height: 100%;" aria-label="16. BENEFICIARY OR BENEFICIARIES INFORMATION - a. NAME (Last, First, Middle Initial), new row" aria-required="false" tabindex="5000"></textarea></label></div></div><div class="xfaWrapper" style="width: 79.2px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.248457px; left: -0.248457px; width: calc(100% + 0.496913px); height: calc(100% + 0.496913px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19781" class="xfaField xfaFont xfaWrapped" xfaname="SSN" title="b. Social security number. Do not include dashes."><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19781" class="xfaTextfield" style="height: 100%;" aria-label="b. Social security number. Do not include dashes." aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 212.4px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19803" class="xfaField xfaFont xfaWrapped" xfaname="Address" title="c. ADDRESS (Street, City, State, ZIP Code)"><label class="xfaLabel xfaLeft"><textarea fieldid="field19803" class="xfaTextfield" style="height: 100%;" aria-label="c. ADDRESS (Street, City, State, ZIP Code)" aria-required="false" tabindex="5000"></textarea></label></div></div><div class="xfaWrapper" style="width: 82.8px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19815" class="xfaField xfaFont xfaWrapped" xfaname="Rel" title="d. RELATIONSHIP"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19815" class="xfaTextfield" style="height: 100%;" aria-label="d. RELATIONSHIP" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 45.36px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none solid solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19827" class="xfaField xfaFont xfaWrapped" xfaname="Share" title="e. SHARE (percentage)"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19827" class="xfaTextfield" style="height: 100%;" aria-label="e. SHARE (percentage)" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 12.24px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw19847" class="xfaDraw xfaFont xfaWrapped" xfaname="PercentSign"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px;"><span>%</span></div></div></div></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 18px; position: relative; align-self: start;"><div data-element-id="subform19873" class="xfaSubform xfaLrTb xfaWrapped" xfaname="NameSSNAddRelShare1"><div class="xfaLr"><div class="xfaWrapper" style="width: 14.4px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 1.42px 0.72px 1.42px 1.42px;" data-element-id="field19874" class="xfaField xfaFont xfaDisabled xfaWrapped" xfaname="rowCount"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19874" class="xfaTextfield" style="border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 100%;" aria-required="false" tabindex="5000" value="6)"></label></div></div><div class="xfaWrapper" style="width: 129.6px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19897" class="xfaField xfaFont xfaWrapped" xfaname="Name" title="16. BENEFICIARY OR BENEFICIARIES INFORMATION - a. NAME (Last, First, Middle Initial), new row"><label class="xfaLabel xfaLeft"><textarea fieldid="field19897" class="xfaTextfield" style="height: 100%;" aria-label="16. BENEFICIARY OR BENEFICIARIES INFORMATION - a. NAME (Last, First, Middle Initial), new row" aria-required="false" tabindex="5000"></textarea></label></div></div><div class="xfaWrapper" style="width: 79.2px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.248457px; left: -0.248457px; width: calc(100% + 0.496913px); height: calc(100% + 0.496913px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19915" class="xfaField xfaFont xfaWrapped" xfaname="SSN" title="b. Social security number. Do not include dashes."><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19915" class="xfaTextfield" style="height: 100%;" aria-label="b. Social security number. Do not include dashes." aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 212.4px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19937" class="xfaField xfaFont xfaWrapped" xfaname="Address" title="c. ADDRESS (Street, City, State, ZIP Code)"><label class="xfaLabel xfaLeft"><textarea fieldid="field19937" class="xfaTextfield" style="height: 100%;" aria-label="c. ADDRESS (Street, City, State, ZIP Code)" aria-required="false" tabindex="5000"></textarea></label></div></div><div class="xfaWrapper" style="width: 82.8px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19949" class="xfaField xfaFont xfaWrapped" xfaname="Rel" title="d. RELATIONSHIP"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19949" class="xfaTextfield" style="height: 100%;" aria-label="d. RELATIONSHIP" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 45.36px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none solid solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field19961" class="xfaField xfaFont xfaWrapped" xfaname="Share" title="e. SHARE (percentage)"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field19961" class="xfaTextfield" style="height: 100%;" aria-label="e. SHARE (percentage)" aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 12.24px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw19981" class="xfaDraw xfaFont xfaWrapped" xfaname="PercentSign"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px;"><span>%</span></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 328.44px; position: relative; align-self: start;"><div data-element-id="subform13878" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Section6Block"><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.500457px; left: -0.749055px; width: calc(100% + 1.49811px); height: calc(100% + 1.00091px); border-width: 1px 1.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: normal; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; background-color: rgb(192, 192, 192); padding: 1.42px 1.42px 1.42px 7.2px;" data-element-id="draw13879" class="xfaDraw xfaFont xfaWrapped" xfaname="Section6" role="heading" aria-level="1"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="letter-spacing: 0px;">SECTION VI - FEDERAL INCOME TAX WITHHOLDING INFORMATION<span> </span><span style="font-weight: normal; font-style: italic;">(Submit information in Items 17 – 21 in lieu of IRS Form W-4 for tax purposes.)</span></p><p style="font-weight: normal; letter-spacing: 0px;">Please refer to the following IRS hyperlink for withholding questions:<span> </span><a style="color: rgb(0, 0, 0);" title="https://www.irs.gov/forms-instructions" href="https://www.irs.gov/forms-instructions" target="" rel="noopener noreferrer nofollow">https://www.irs.gov/forms-instructions</a></p></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 288px; height: 118.08px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid none;"></div><div data-element-id="subform13899" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Block17"><div class="xfaLr"><div class="xfaWrapper" style="width: 288px; height: 18.72px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px 0px 1.42px 3.6px;" data-element-id="draw13900" class="xfaDraw xfaFont xfaWrapped" xfaname="MaritalStatus"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 12.96px; padding-top: 2px; padding-bottom: 0px; text-indent: -12.96px;" class="xfaRich"><p style="letter-spacing: 0px;">17. MARITAL STATUS<span> </span><span style="font-size: 6.93px; font-weight: normal; font-style: italic;">(Check one)</span></p></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 16.56px; height: 17.28px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw13918" class="xfaDraw xfaFont xfaWrapped" xfaname="buffer"></div></div><div class="xfaWrapper" style="width: 271.44px; height: 99.36px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: none;"></div><div data-element-id="subform13923" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Checklist"><div class="xfaLr"><div class="xfaWrapper" style="width: 271.44px; height: 18.72px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field13924" class="xfaField xfaFont xfaWrapped" xfaname="Single" title="SECTION VI - FEDERAL INCOME TAX WITHHOLDING INFORMATION - 17. MARITAL STATUS (Check one) - Select for "SINGLE OR MARRIED FILING SEPARATELY.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; width: 252px;" class="xfaCaptionForCheckButton"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>SINGLE OR MARRIED FILING SEPARATELY</span></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field13924" type="checkbox" xfaon="1" xfaoff="0" aria-label="SECTION VI - FEDERAL INCOME TAX WITHHOLDING INFORMATION - 17. MARITAL STATUS (Check one) - Select for "SINGLE OR MARRIED FILING SEPARATELY."" aria-required="false" tabindex="5000" value="0"></label></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 271.44px; height: 18.72px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field13949" class="xfaField xfaFont xfaWrapped" xfaname="Married" title="17. MARITAL STATUS (Check one) - Select for "MARRIED FILING JOINTLY (Or qualifying widow/er).""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 252px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left;" class="xfaRich"><p style="font-weight: bold; letter-spacing: 0px;">MARRIED FILING JOINTLY<span style="font-weight: normal;"><span> </span></span><span style="font-weight: normal; font-style: italic;">(Or qualifying widow/er)</span></p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field13949" type="checkbox" xfaon="1" xfaoff="0" aria-label="17. MARITAL STATUS (Check one) - Select for "MARRIED FILING JOINTLY (Or qualifying widow/er)."" aria-required="false" tabindex="5000" value="0"></label></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 271.44px; height: 18.72px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field13974" class="xfaField xfaFont xfaWrapped" xfaname="MarriedButW" title="17. MARITAL STATUS (Check one) - Select for "MARRIED FILING JOINTLY (Or qualifying widow/er).""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 252px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left;" class="xfaRich"><p style="font-weight: bold; text-decoration: none; letter-spacing: 0px;">MARRIED, BUT WITHHOLDING AT THE HIGHER SINGLE RATE</p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field13974" type="checkbox" xfaon="1" xfaoff="0" aria-label="17. MARITAL STATUS (Check one) - Select for "MARRIED FILING JOINTLY (Or qualifying widow/er)."" aria-required="false" tabindex="5000" value="0"></label></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 248.4px; height: 43.2px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 3.6px 2.83px 0px;" data-element-id="field13999" class="xfaField xfaFont xfaWrapped" xfaname="HeadH" title="17. MARITAL STATUS (Check one) - Select for "HEAD OF HOUSEHOLD (Check only if you're unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual).""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 229px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: start; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="font-weight: bold; letter-spacing: 0px;">HEAD OF HOUSEHOLD<span style="font-weight: normal;"><span> </span></span></p><p style="font-style: italic; letter-spacing: 0px;">(Check only if you're unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual)</p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field13999" type="checkbox" xfaon="1" xfaoff="0" aria-label="17. MARITAL STATUS (Check one) - Select for "HEAD OF HOUSEHOLD (Check only if you're unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual)."" aria-required="false" tabindex="5000" value="0"></label></div></div></div></div></div></div></div></div><div class="xfaWrapper" style="width: 288px; height: 134.64px; position: relative; align-self: start;"><div data-element-id="subform14038" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Block18"><div class="xfaLr"><div class="xfaWrapper" style="width: 288px; height: 43.2px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px;" data-element-id="draw14039" class="xfaDraw xfaFont xfaWrapped" xfaname="Text2"><div style="display: flex; flex-direction: column; justify-content: start; text-align: left; padding-left: 12.96px; padding-top: 2px; padding-bottom: 0px; text-indent: -12.96px;" class="xfaRich"><p style="letter-spacing: 0px;">18. MULTIPLE JOBS OR SPOUSE WORKS<span> </span><span style="font-weight: normal; font-style: italic;">(Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs)</span></p></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 288px; height: 46.8px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 0px 1.42px;" data-element-id="draw14047" class="xfaDraw xfaFont xfaWrapped" xfaname="Text4"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 3.6px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="margin-bottom: 2px; text-decoration: none; letter-spacing: 0px;">Do only one of the following:</p><p style="margin-bottom: 2px; text-decoration: none; letter-spacing: 0px;">(a) Use the estimator at https://www.irs.gov/individuals/tax-withholding-estimator for most accurate withholding<span style="font-weight: bold;">,</span></p><p style="margin-bottom: 2px; font-weight: bold; text-decoration: none; letter-spacing: 0px;">or</p></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 252px; height: 44.64px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: none none none solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 1.44px 1.42px 0px;" data-element-id="draw14055" class="xfaDraw xfaFont xfaWrapped" xfaname="Text3"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: start; text-align: left; padding-left: 3.6px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>(b) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld.</span></div></div></div><div class="xfaWrapper" style="width: 21.6px; height: 44.64px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 21.6px 5.76px 0px 0px;" data-element-id="field14069" class="xfaField xfaFont xfaWrapped" xfaname="CheckBox1" title="18. MULTIPLE JOBS OR SPOUSE WORKS * Select if there are only 2 jobs total."><label class="xfaLabel xfaLeft"><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field14069" type="checkbox" xfaon="1" xfaoff="0" aria-label="18. MULTIPLE JOBS OR SPOUSE WORKS * Select if there are only 2 jobs total." aria-required="false" tabindex="5000" value="0"></label></div></div></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 21.72px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div data-element-id="subform14087" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Citizen"><div class="xfaLr"><div class="xfaWrapper" style="width: 172.8px; height: 21.6px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none none solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px 0px 1.42px 3.6px;" data-element-id="draw14088" class="xfaDraw xfaFont xfaWrapped" xfaname="section_23"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>19. ARE YOU A UNITED STATES CITIZEN?</span></div></div></div><div class="xfaWrapper" style="width: 136.8px; height: 21.72px; position: relative; align-self: start;"><div data-element-id="subform14106" class="xfaSubform xfaLrTb xfaWrapped" xfaname="YesNo"><div class="xfaLr"><div class="xfaWrapper" style="width: 36px; height: 21.72px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field14107" class="xfaField xfaFont xfaWrapped" xfaname="yes" title="19. ARE YOU A UNITED STATES CITIZEN? - Select for "yes, I am a United States citizen.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 17px;" class="xfaCaptionForCheckButton"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>Yes</span></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field14107" type="checkbox" xfaon="1" xfaoff="0" aria-label="19. ARE YOU A UNITED STATES CITIZEN? - Select for "yes, I am a United States citizen."" aria-required="false" tabindex="5000" value="0"></label></div></div><div class="xfaWrapper" style="width: 100.8px; height: 21.6px; position: relative; align-self: start;"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 0px 2.83px;" data-element-id="field14138" class="xfaField xfaFont xfaWrapped" xfaname="no" title="19. ARE YOU A UNITED STATES CITIZEN? - Select for "no, I am not a United States citizen.""><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 81px;" class="xfaCaptionForCheckButton"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="letter-spacing: 0px;">No<span> </span><span style="font-style: italic;">(See instructions)</span></p></div></div><input class="xfaCheckbox" style="height: 100%; width: 10px;" fieldid="field14138" type="checkbox" xfaon="1" xfaoff="0" aria-label="19. ARE YOU A UNITED STATES CITIZEN? - Select for "no, I am not a United States citizen."" aria-required="false" tabindex="5000" value="0"></label></div></div></div></div></div></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 288px; height: 121.68px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div data-element-id="subform14166" class="xfaSubform xfaLrTb xfaWrapped" xfaname="ClaimDependents"><div class="xfaLr"><div class="xfaWrapper" style="width: 288px; height: 15.84px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px 0px 1.42px 3.6px;" data-element-id="draw14167" class="xfaDraw xfaFont xfaWrapped" xfaname="Title"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 12.96px; padding-top: 0px; padding-bottom: 0px; text-indent: -12.96px;"><span>20. CLAIM DEPENDENTS</span></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 288px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 1.42px 0px 1.42px 3.6px;" data-element-id="draw14179" class="xfaDraw xfaFont xfaWrapped" xfaname="ifYourIncome"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>If your income will be $200,000 or less ($400,000 or less if married filing jointly)</span></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 234px; height: 32.4px; position: relative; align-self: start;"><div data-element-id="subform14191" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Multp17"><div class="xfaLr"><div class="xfaWrapper" style="width: 234px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 2.84px 0px 2.84px 3.6px;" data-element-id="field14192" class="xfaField xfaFont xfaWrapped" xfaname="Multp17" title="20. CLAIM DEPENDENTS - Number of qualifying children under age 17"><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 6.93px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 209px;" class="xfaCaption"><div style="display: flex; flex-direction: column; justify-content: end; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="font-size: 7.92px; letter-spacing: 0px;">Number of qualifying children under age 17</p></div></div><input type="text" fieldid="field14192" class="xfaTextfield" style="border-style: none none solid; border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 100%;" aria-label="20. CLAIM DEPENDENTS - Number of qualifying children under age 17" aria-required="false" tabindex="5000" maxlength="2"></label></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 234px; height: 14.4px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: italic; font-size: 6.93px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 1.42px 3.6px;" data-element-id="draw14219" class="xfaDraw xfaFont xfaWrapped" xfaname="Multp17Note"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: right; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>(Multiply the number of qualifying children under age 17 by $2,000)</span></div></div></div></div></div></div><div class="xfaWrapper" style="width: 54px; height: 32.4px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 2.83px 2.83px 7.2px;" data-element-id="field14231" class="xfaField xfaFont xfaReadOnly xfaWrapped" xfaname="Multp_box" title="20. CLAIM DEPENDENTS - Multiply the number of qualifying children under age 17 by $2,000."><label class="xfaLabel xfaLeft"><input type="text" fieldid="field14231" class="xfaTextfield" style="border-style: none none solid; border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 100%;" aria-label="20. CLAIM DEPENDENTS - Multiply the number of qualifying children under age 17 by $2,000." aria-required="false" tabindex="5000"></label></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 234px; height: 32.4px; position: relative; align-self: start;"><div data-element-id="subform14257" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Multp500"><div class="xfaLr"><div class="xfaWrapper" style="width: 234px; height: 18px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: none none none solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 2.84px 0px 2.84px 3.6px;" data-element-id="field14258" class="xfaField xfaFont xfaWrapped" xfaname="Multp500" title="20. CLAIM DEPENDENTS - Number of other dependents"><label class="xfaLabel xfaRight"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; width: 209px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: end; text-align: left;"><span>Number of other dependents</span></div></div><input type="text" fieldid="field14258" class="xfaTextfield" style="border-style: none none solid; border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 100%;" aria-label="20. CLAIM DEPENDENTS - Number of other dependents" aria-required="false" tabindex="5000" maxlength="2"></label></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 234px; height: 14.4px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: italic; font-size: 6.93px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: normal; padding: 1.42px 3.6px 1.42px 23.04px;" data-element-id="draw14289" class="xfaDraw xfaFont xfaWrapped" xfaname="Multp17Note"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>(Multiply the number of other dependents by $500)</span></div></div></div></div></div></div><div class="xfaWrapper" style="width: 54px; height: 32.4px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 2.83px 2.83px 7.2px;" data-element-id="field14301" class="xfaField xfaFont xfaReadOnly xfaWrapped" xfaname="Multp500_box" title="20. CLAIM DEPENDENTS - Multiply the number of other dependents by $500."><label class="xfaLabel xfaLeft"><input type="text" fieldid="field14301" class="xfaTextfield" style="border-style: none none solid; border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 100%;" aria-label="20. CLAIM DEPENDENTS - Multiply the number of other dependents by $500." aria-required="false" tabindex="5000"></label></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 190.8px; height: 23.04px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: none none solid solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px 0px 1.42px 3.6px;" data-element-id="draw14330" class="xfaDraw xfaFont xfaWrapped" xfaname="addAmts"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>Add the amounts above and enter the total here:</span></div></div></div><div class="xfaWrapper" style="width: 97.2px; height: 23.04px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 2.83px;" data-element-id="field14348" class="xfaField xfaFont xfaReadOnly xfaWrapped" xfaname="addAmts_box" title="20. CLAIM DEPENDENTS - Add the amounts above and enter the total here."><label class="xfaLabel xfaLeft"><input type="text" fieldid="field14348" class="xfaTextfield" style="border-style: none none solid; border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 100%;" aria-label="20. CLAIM DEPENDENTS - Add the amounts above and enter the total here." aria-required="false" tabindex="5000"></label></div></div></div></div></div><div class="xfaWrapper" style="width: 288px; height: 121.68px; position: relative; align-self: start;"><div data-element-id="subform14375" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Blocks21-22"><div class="xfaLr"><div class="xfaWrapper" style="width: 216px; height: 60.84px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none solid solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px 0px 1.42px 3.6px;" data-element-id="draw14376" class="xfaDraw xfaFont xfaWrapped" xfaname="_21"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 3.6px; padding-top: 0px; padding-bottom: 0px; text-indent: -3.6px;" class="xfaRich"><p style="text-indent: -3.6px; letter-spacing: 0px; padding-left: 3.6px;">21. OTHER INCOME<span style="font-style: italic;"><span> </span></span><span style="font-weight: normal; font-style: italic;">(Not from jobs)</span><span style="font-weight: normal;">. If you want tax withheld for other income you expect this year that won't have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income:</span></p></div></div></div><div class="xfaWrapper" style="width: 72px; height: 60.84px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 2.83px;" data-element-id="field14394" class="xfaField xfaFont xfaWrapped" xfaname="_21box" title="21. OTHER INCOME (Not from jobs). If you want tax withheld for other income you expect this year that won't have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income:"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field14394" class="xfaTextfield" style="border-style: none none solid; border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 100%;" aria-label="21. OTHER INCOME (Not from jobs). If you want tax withheld for other income you expect this year that won't have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income:" aria-required="false" tabindex="5000"></label></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 216px; height: 60.84px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none solid solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px 0px 1.42px 3.6px;" data-element-id="draw14424" class="xfaDraw xfaFont xfaWrapped" xfaname="_22"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 3.6px; padding-top: 0px; padding-bottom: 0px; text-indent: -3.6px;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">22. DEDUCTIONS<span> </span><span style="font-weight: normal;">If you expect to claim deductions other than the standard deduction and want to reduce your withholding, review the Deductions Worksheet on page 3 of the IRS Form W-4 and enter the result here:</span></p><p style="font-weight: normal; font-style: italic; text-decoration: none; letter-spacing: 0px;"><span> </span>(Estimate your deductions this year OR provide previous year's total deductions)</p></div></div></div><div class="xfaWrapper" style="width: 72px; height: 60.84px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 2.83px;" data-element-id="field14442" class="xfaField xfaFont xfaWrapped" xfaname="_22box" title="22. DEDUCTIONS If you expect to claim deductions other than the standard deduction and want to reduce your withholding, review the Deductions Worksheet on page 3 of the IRS Form W-4 and enter the result here:
(Estimate your deductions this year OR provide previous year's total deductions)"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field14442" class="xfaTextfield" style="border-style: none none solid; border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 100%;" aria-label="22. DEDUCTIONS If you expect to claim deductions other than the standard deduction and want to reduce your withholding, review the Deductions Worksheet on page 3 of the IRS Form W-4 and enter the result here:
(Estimate your deductions this year OR provide previous year's total deductions)" aria-required="false" tabindex="5000"></label></div></div></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 504px; height: 21.6px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid none solid solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px 0px 1.42px 3.6px;" data-element-id="draw14472" class="xfaDraw xfaFont xfaWrapped" xfaname="section_22"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">23. EXTRA WITHHOLDINGS.<span> </span><span style="font-weight: normal;">Enter any additional tax you want withheld each month:</span></p></div></div></div><div class="xfaWrapper" style="width: 72px; height: 21.6px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 2.83px;" data-element-id="field14490" class="xfaField xfaFont xfaWrapped" xfaname="section_22box" title="23. EXTRA WITHHOLDINGS. Enter any additional tax you want withheld each month:"><label class="xfaLabel xfaLeft"><input type="text" fieldid="field14490" class="xfaTextfield" style="border-style: none none solid; border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 100%;" aria-label="23. EXTRA WITHHOLDINGS. Enter any additional tax you want withheld each month:" aria-required="false" tabindex="5000"></label></div></div></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 67.68px; position: relative; align-self: start;"><div data-element-id="subform14520" class="xfaSubform xfaLrTb xfaWrapped" xfaname="Section7Block"><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 21.6px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.500457px; left: -0.500457px; width: calc(100% + 1.00091px); height: calc(100% + 1.00091px); border-width: 1px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: normal; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; background-color: rgb(192, 192, 192); padding: 1.42px 1.42px 1.42px 7.2px;" data-element-id="draw14521" class="xfaDraw xfaFont xfaWrapped" xfaname="Section7" role="heading" aria-level="1"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="letter-spacing: 0px;">SECTION VII - VOLUNTARY STATE TAX WITHHOLDING INFORMATION<span> </span><span style="font-weight: normal; font-style: italic;">(Complete only if monthly withholding is desired.)</span></p></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 115.2px; height: 46.08px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.248457px; left: -0.248457px; width: calc(100% + 0.496913px); height: calc(100% + 0.496913px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field14535" class="xfaField xfaFont xfaWrapped" xfaname="StateRecvTax" title="SECTION VII - VOLUNTARY STATE TAX WITHHOLDING INFORMATION (Complete only if monthly withholding is desired.) - 24. STATE DESIGNATED TO RECEIVE TAX (select from drop-down list)"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 18px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 14.4px; padding-top: 0px; padding-bottom: 0px; text-indent: -14.4px;"><span>24. STATE DESIGNATED TO RECEIVE TAX </span></div></div><select class="xfaSelect" fieldid="field14535" style="border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 24.24px;" aria-label="SECTION VII - VOLUNTARY STATE TAX WITHHOLDING INFORMATION (Complete only if monthly withholding is desired.) - 24. STATE DESIGNATED TO RECEIVE TAX (select from drop-down list)" aria-required="false" tabindex="5000"><option selected="true" hidden="true"> </option><option value="0" style="font-size: calc(10px * var(--scale-factor));"> </option><option value="AL" style="font-size: calc(10px * var(--scale-factor));"> Alabama</option><option value="AK" style="font-size: calc(10px * var(--scale-factor));"> Alaska</option><option value="AZ" style="font-size: calc(10px * var(--scale-factor));"> Arizona</option><option value="AR" style="font-size: calc(10px * var(--scale-factor));"> Arkansas</option><option value="CA" style="font-size: calc(10px * var(--scale-factor));"> California</option><option value="CO" style="font-size: calc(10px * var(--scale-factor));"> Colorado</option><option value="CT" style="font-size: calc(10px * var(--scale-factor));"> Connecticut</option><option value="DE" style="font-size: calc(10px * var(--scale-factor));"> Delaware</option><option value="DC" style="font-size: calc(10px * var(--scale-factor));"> District of Columbia</option><option value="FL" style="font-size: calc(10px * var(--scale-factor));"> Florida</option><option value="GA" style="font-size: calc(10px * var(--scale-factor));"> Georgia</option><option value="HI" style="font-size: calc(10px * var(--scale-factor));"> Hawaii</option><option value="ID" style="font-size: calc(10px * var(--scale-factor));"> Idaho</option><option value="IL" style="font-size: calc(10px * var(--scale-factor));"> Illinois</option><option value="IN" style="font-size: calc(10px * var(--scale-factor));"> Indiana</option><option value="IA" style="font-size: calc(10px * var(--scale-factor));"> Iowa</option><option value="KS" style="font-size: calc(10px * var(--scale-factor));"> Kansas</option><option value="KY" style="font-size: calc(10px * var(--scale-factor));"> Kentucky</option><option value="LA" style="font-size: calc(10px * var(--scale-factor));"> Louisiana</option><option value="ME" style="font-size: calc(10px * var(--scale-factor));"> Maine</option><option value="MD" style="font-size: calc(10px * var(--scale-factor));"> Maryland</option><option value="MA" style="font-size: calc(10px * var(--scale-factor));"> Massachusetts</option><option value="MI" style="font-size: calc(10px * var(--scale-factor));"> Michigan</option><option value="MN" style="font-size: calc(10px * var(--scale-factor));"> Minnesota</option><option value="MS" style="font-size: calc(10px * var(--scale-factor));"> Mississippi</option><option value="MO" style="font-size: calc(10px * var(--scale-factor));"> Missouri</option><option value="MT" style="font-size: calc(10px * var(--scale-factor));"> Montana</option><option value="NE" style="font-size: calc(10px * var(--scale-factor));"> Nebraska</option><option value="NV" style="font-size: calc(10px * var(--scale-factor));"> Nevada</option><option value="NH" style="font-size: calc(10px * var(--scale-factor));"> New Hampshire</option><option value="NJ" style="font-size: calc(10px * var(--scale-factor));"> New Jersey</option><option value="NM" style="font-size: calc(10px * var(--scale-factor));"> New Mexico</option><option value="NY" style="font-size: calc(10px * var(--scale-factor));"> New York</option><option value="NC" style="font-size: calc(10px * var(--scale-factor));"> North Carolina</option><option value="ND" style="font-size: calc(10px * var(--scale-factor));"> North Dakota</option><option value="OH" style="font-size: calc(10px * var(--scale-factor));"> Ohio</option><option value="OK" style="font-size: calc(10px * var(--scale-factor));"> Oklahoma</option><option value="OR" style="font-size: calc(10px * var(--scale-factor));"> Oregon</option><option value="PA" style="font-size: calc(10px * var(--scale-factor));"> Pennsylvania</option><option value="RI" style="font-size: calc(10px * var(--scale-factor));"> Rhode Island</option><option value="SC" style="font-size: calc(10px * var(--scale-factor));"> South Carolina</option><option value="SD" style="font-size: calc(10px * var(--scale-factor));"> South Dakota</option><option value="TN" style="font-size: calc(10px * var(--scale-factor));"> Tennessee</option><option value="TX" style="font-size: calc(10px * var(--scale-factor));"> Texas</option><option value="UT" style="font-size: calc(10px * var(--scale-factor));"> Utah</option><option value="VT" style="font-size: calc(10px * var(--scale-factor));"> Vermont</option><option value="VA" style="font-size: calc(10px * var(--scale-factor));"> Virginia</option><option value="WA" style="font-size: calc(10px * var(--scale-factor));"> Washington</option><option value="WV" style="font-size: calc(10px * var(--scale-factor));"> West Virginia</option><option value="WI" style="font-size: calc(10px * var(--scale-factor));"> Wisconsin</option><option value="WY" style="font-size: calc(10px * var(--scale-factor));"> Wyoming</option></select></label></div></div><div class="xfaWrapper" style="width: 108px; height: 46.08px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field14660" class="xfaField xfaFont xfaWrapped" xfaname="MonthlyAmt" title="Enter monthly amount (whole dollar amount not less than ten dollars)."><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 31px;" class="xfaCaption"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 12.96px; padding-top: 0px; padding-bottom: 0px; text-indent: -12.96px;" class="xfaRich"><p style="letter-spacing: 0px;">25. MONTHLY AMOUNT<span> </span><span style="font-size: 6.93px; font-weight: normal; font-style: italic;">(Whole dollar amount not less than $10.00)</span></p></div></div><input type="text" fieldid="field14660" class="xfaTextfield" style="height: 12.24px;" aria-label="Enter monthly amount (whole dollar amount not less than ten dollars)." aria-required="false" tabindex="5000"></label></div></div><div class="xfaWrapper" style="width: 352.8px; height: 46.08px; position: relative; align-self: start;"><div data-element-id="subform14686" class="xfaSubform xfaLrTb xfaWrapped" xfaname="ResidAddress"><div class="xfaLr"><div class="xfaWrapper" style="width: 352.8px; height: 14.4px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.25px; left: -0.25px; width: calc(100% + 0.5px); height: calc(100% + 0.5px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid solid none;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; padding: 1.42px 1.42px 1.42px 2.16px;" data-element-id="draw14687" class="xfaDraw xfaFont xfaWrapped" xfaname="ResidAddress"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">26. RESIDENCE ADDRESS<span> </span><span style="font-size: 6.93px; font-weight: normal; font-style: italic;">(If different from address listed in Item 9)</span><span> </span></p></div></div></div></div><div class="xfaLr"><div class="xfaWrapper" style="width: 177.12px; height: 31.68px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.248457px; left: -0.248457px; width: calc(100% + 0.496913px); height: calc(100% + 0.496913px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field14702" class="xfaField xfaFont xfaWrapped" xfaname="Street" title="26. RESIDENCE ADDRESS (If different from address listed in Item 9) - a. STREET (Include apartment number)"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="letter-spacing: 0px;">a. STREET<span> </span><span style="font-weight: normal; font-style: italic;">(Include apartment number)</span></p></div></div><textarea fieldid="field14702" class="xfaTextfield" style="height: 19.84px;" aria-label="26. RESIDENCE ADDRESS (If different from address listed in Item 9) - a. STREET (Include apartment number)" aria-required="false" tabindex="5000"></textarea></label></div></div><div class="xfaWrapper" style="width: 72px; height: 31.68px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.248457px; left: -0.248457px; width: calc(100% + 0.496913px); height: calc(100% + 0.496913px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field14719" class="xfaField xfaFont xfaWrapped" xfaname="City" title="26. RESIDENCE ADDRESS (If different from address listed in Item 9) - b. CITY"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>b. CITY</span></div></div><textarea fieldid="field14719" class="xfaTextfield" style="height: 19.84px;" aria-label="26. RESIDENCE ADDRESS (If different from address listed in Item 9) - b. CITY" aria-required="false" tabindex="5000"></textarea></label></div></div><div class="xfaWrapper" style="width: 46.08px; height: 31.68px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.248457px; left: -0.248457px; width: calc(100% + 0.496913px); height: calc(100% + 0.496913px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field14736" class="xfaField xfaFont xfaWrapped" xfaname="State" title="26. RESIDENCE ADDRESS (If different from address listed in Item 9) - c. STATE (select from drop-down list)"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;"><span>c. STATE</span></div></div><select class="xfaSelect" fieldid="field14736" style="border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 18.84px;" aria-label="26. RESIDENCE ADDRESS (If different from address listed in Item 9) - c. STATE (select from drop-down list)" aria-required="false" tabindex="5000"><option selected="true" hidden="true"> </option><option value="0" style="font-size: calc(10px * var(--scale-factor));"> </option><option value="AL" style="font-size: calc(10px * var(--scale-factor));">AL</option><option value="AK" style="font-size: calc(10px * var(--scale-factor));">AK</option><option value="AZ" style="font-size: calc(10px * var(--scale-factor));">AZ</option><option value="AR" style="font-size: calc(10px * var(--scale-factor));">AR</option><option value="CA" style="font-size: calc(10px * var(--scale-factor));">CA</option><option value="CO" style="font-size: calc(10px * var(--scale-factor));">CO</option><option value="CT" style="font-size: calc(10px * var(--scale-factor));">CT</option><option value="DE" style="font-size: calc(10px * var(--scale-factor));">DE</option><option value="DC" style="font-size: calc(10px * var(--scale-factor));">DC</option><option value="FL" style="font-size: calc(10px * var(--scale-factor));">FL</option><option value="GA" style="font-size: calc(10px * var(--scale-factor));">GA</option><option value="HI" style="font-size: calc(10px * var(--scale-factor));">HI</option><option value="ID" style="font-size: calc(10px * var(--scale-factor));">ID</option><option value="IL" style="font-size: calc(10px * var(--scale-factor));">IL</option><option value="IN" style="font-size: calc(10px * var(--scale-factor));">IN</option><option value="IA" style="font-size: calc(10px * var(--scale-factor));">IA</option><option value="KS" style="font-size: calc(10px * var(--scale-factor));">KS</option><option value="KY" style="font-size: calc(10px * var(--scale-factor));">KY</option><option value="LA" style="font-size: calc(10px * var(--scale-factor));">LA</option><option value="ME" style="font-size: calc(10px * var(--scale-factor));">ME</option><option value="MD" style="font-size: calc(10px * var(--scale-factor));">MD</option><option value="MA" style="font-size: calc(10px * var(--scale-factor));">MA</option><option value="MI" style="font-size: calc(10px * var(--scale-factor));">MI</option><option value="MN" style="font-size: calc(10px * var(--scale-factor));">MN</option><option value="MS" style="font-size: calc(10px * var(--scale-factor));">MS</option><option value="MO" style="font-size: calc(10px * var(--scale-factor));">MO</option><option value="MT" style="font-size: calc(10px * var(--scale-factor));">MT</option><option value="NE" style="font-size: calc(10px * var(--scale-factor));">NE</option><option value="NV" style="font-size: calc(10px * var(--scale-factor));">NV</option><option value="NH" style="font-size: calc(10px * var(--scale-factor));">NH</option><option value="NJ" style="font-size: calc(10px * var(--scale-factor));">NJ</option><option value="NM" style="font-size: calc(10px * var(--scale-factor));">NM</option><option value="NY" style="font-size: calc(10px * var(--scale-factor));">NY</option><option value="NC" style="font-size: calc(10px * var(--scale-factor));">NC</option><option value="ND" style="font-size: calc(10px * var(--scale-factor));">ND</option><option value="OH" style="font-size: calc(10px * var(--scale-factor));">OH</option><option value="OK" style="font-size: calc(10px * var(--scale-factor));">OK</option><option value="OR" style="font-size: calc(10px * var(--scale-factor));">OR</option><option value="PA" style="font-size: calc(10px * var(--scale-factor));">PA</option><option value="RI" style="font-size: calc(10px * var(--scale-factor));">RI</option><option value="SC" style="font-size: calc(10px * var(--scale-factor));">SC</option><option value="SD" style="font-size: calc(10px * var(--scale-factor));">SD</option><option value="TN" style="font-size: calc(10px * var(--scale-factor));">TN</option><option value="TX" style="font-size: calc(10px * var(--scale-factor));">TX</option><option value="UT" style="font-size: calc(10px * var(--scale-factor));">UT</option><option value="VT" style="font-size: calc(10px * var(--scale-factor));">VT</option><option value="VA" style="font-size: calc(10px * var(--scale-factor));">VA</option><option value="WA" style="font-size: calc(10px * var(--scale-factor));">WA</option><option value="WV" style="font-size: calc(10px * var(--scale-factor));">WV</option><option value="WI" style="font-size: calc(10px * var(--scale-factor));">WI</option><option value="WY" style="font-size: calc(10px * var(--scale-factor));">WY</option></select></label></div></div><div class="xfaWrapper" style="width: 57.6px; height: 31.68px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.248457px; left: -0.248457px; width: calc(100% + 0.496913px); height: calc(100% + 0.496913px); border-width: 0.5px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 9.9px; font-family: "Times New Roman"; line-height: 1.347; font-weight: normal; padding: 1.42px;" data-element-id="field14861" class="xfaField xfaFont xfaWrapped" xfaname="ZipCode" title="26. RESIDENCE ADDRESS (If different from address listed in Item 9) - d. ZIP CODE"><label class="xfaLabel xfaTop"><div style="font-kerning: none; letter-spacing: 0px; font-style: normal; font-size: 7.92px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; height: 9px;" class="xfaCaption"><div class="xfaRich" style="display: flex; flex-direction: column; justify-content: center; text-align: left; padding-left: 0px;"><span>d. ZIP CODE</span></div></div><input type="text" fieldid="field14861" class="xfaTextfield" style="border-width: 0.5px; border-color: rgb(0, 0, 0); margin: 0px; height: 18.84px;" aria-label="26. RESIDENCE ADDRESS (If different from address listed in Item 9) - d. ZIP CODE" aria-required="false" tabindex="5000"></label></div></div></div></div></div></div></div></div></div></div></div><div data-element-id="subform14892" class="xfaSubform xfaLrTb" style="width: 576px; height: auto; align-self: start;" xfaname="page3"><div class="xfaLr"><div class="xfaWrapper" style="width: 576px; height: 28.8px; position: relative; align-self: start;"><div class="xfaBorder" style="top: -0.500032px; left: -0.500457px; width: calc(100% + 1.00091px); height: calc(100% + 1.00006px); border-width: 1px; border-color: rgb(0, 0, 0); border-style: solid;"></div><div style="font-kerning: normal; letter-spacing: 0px; font-style: normal; font-size: 8.91px; font-family: "Arial-PdfJS-XFA"; line-height: 1.2; font-weight: bold; background-color: rgb(192, 192, 192); padding: 1.42px 1.42px 1.42px 7.2px;" data-element-id="draw14894" class="xfaDraw xfaFont xfaWrapped" xfaname="DontComplete" role="heading" aria-level="1"><div style="display: flex; flex-direction: column; justify-content: center; text-align: center; padding-left: 0px; padding-top: 0px; padding-bottom: 0px; text-indent: 0px;" class="xfaRich"><p style="text-decoration: none; letter-spacing: 0px;">DO NOT COMPLETE PART II,</p><p style="font-style: italic; text-decoration: none; letter-spacing: 0px;">If you ARE NOT covered by the Blended Retirement System OR DO NOT want to elect a lump sum of retired pay</p></div></div></div></div></div></div></div></div></div><div class="annotationLayer" hidden=""></div></div><div class="page" data-page-number="3" role="region" style="width: calc(var(--scale-factor) * 612px); height: calc(var(--scale-factor) * 792px);" aria-label="Page 3"></div><div class="page" data-page-number="4" role="region" style="width: calc(var(--scale-factor) * 612px); height: calc(var(--scale-factor) * 792px);" aria-label="Page 4"></div><div class="page" data-page-number="5" role="region" style="width: calc(var(--scale-factor) * 612px); height: calc(var(--scale-factor) * 792px);" aria-label="Page 5"></div><div class="page" data-page-number="6" role="region" style="width: calc(var(--scale-factor) * 612px); height: calc(var(--scale-factor) * 792px);" aria-label="Page 6"></div><div class="page" data-page-number="7" role="region" style="width: calc(var(--scale-factor) * 612px); height: calc(var(--scale-factor) * 792px);" aria-label="Page 7"></div><div class="page" data-page-number="8" role="region" style="width: calc(var(--scale-factor) * 612px); height: calc(var(--scale-factor) * 792px);" aria-label="Page 8"></div><div class="page" data-page-number="9" role="region" style="width: calc(var(--scale-factor) * 612px); height: calc(var(--scale-factor) * 792px);" aria-label="Page 9"></div><div class="page" data-page-number="10" role="region" style="width: calc(var(--scale-factor) * 612px); height: calc(var(--scale-factor) * 792px);" aria-label="Page 10"></div></div>
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