| Pensioner's Name: |
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| Email: |
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| Confirm Email: |
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| Home Phone: |
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| Work Phone: |
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| Cell Phone: |
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| Address: |
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| City: |
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| State: |
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| Zip: |
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| Type of Pension Pensioner is Receiving: |
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| If Military, Which Type Is It? (Choose All That Apply) |
Regular Military Pension |
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VA Waiver/Compensation Pension Payment |
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SBP (Survivor's Benefit Payment) |
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CRSC (Combat-Related Special Compensation) |
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CRDP (Concurrent Retirement and Disability Pay) |
| If This is a Corporate Pension, What is the Name of the Company:: |
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| The Length of Time that Pensioner will be Receiving the Pension Payment: |
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| How Are You Receiving Your Pension: |
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| If Military Pension What is Your Rank: |
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| If Military Pension What is Your Grade: |
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| Gross Pension Payment: |
$ |
| VA Waiver/Compensation (If Applicable): |
$ |
| CRSC [Combat-Related Special Compensation] (If Applicable): |
$ |
| Concurrent Pay (If Applicable): |
$ |
| Survivor's Benefit Pension (If Applicable): |
$ |
| FITW (Federal Income Tax Withholding): |
$ |
| SITW (State Income Tax Withholding): |
$ |
| SBP [Survivor’s Benefit Pension Withholding] (If Applicable): |
$ |
| Other Allotments and/or Deductions: |
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| Additional Allotments and/or Deductions: |
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| Date of Next Pension Payment: |
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| Is the Pension Assignable: |
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| If Assignable, Please Provide A Contact Person to Verify: |
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| Contact Verification Number: |
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| Reason You Want the Advance: |
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