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[PDF File]Designation of Beneficiary
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Department or agency Bureau or division Location (city, state, and ZIP code) First name, middle initial, and last name of each beneficiary Social Security Number Address (Including ZIP code) Percent or fraction designated Relationship B. Information About the Beneficiary or Beneficiaries (See Back of Part 1 for examples) (type or print)
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[PDF File]CM-010 Civil Case Cover Sheet
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CITY AND ZIP CODE: BRANCH NAME: CASE NAME: CIVIL CASE COVER SHEET Complex Case Designation Unlimited Limited (Amount (Amount Counter Joinder demanded Filed with first demanded is appearance by defendant exceeds $25,000) $25,000 or less) (Cal. Rules of Court, rule 3.402) Items 1–6 below must be completed (see instructions on page 2). 1.
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[PDF File]Consent for Release of Information
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acting on behalf of a minor child, you may complete this form to release only the minor's non-medical records. We may charge a fee for providing information unrelated to the administration of a program under the Social Security Act. NOTE: Do not use this form to: • Request the release of medical records on behalf of a minor child.
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[DOC File]LEAVE REQUEST FORM/AUTHORIZATION - United States Navy
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starts on a non-workday, the starting hour may be 0001 if not contrary to command policy. b. Block 15 - The hour for ending leave may not be later than the beginning of your normal workday if the day of return is a workday. If leave ends on a non-workday the ending hour may be 2400 if not contrary to command policy. 4.
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[PDF File]Form W-9 (Rev. October 2018)
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City, state, and ZIP code. Requester’s name and address (optional) 7. List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN).
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[DOC File]Aid Codes Master Chart (aid codes) - Medi-Cal
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The aid codes in this chart are meant to assist providers in identifying the types of services for which Medi-Cal and public health program recipients are eligible. The chart includes only aid codes used to bill for services through the Medi-Cal claims processing system and for other non Medi-Cal programs that
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[PDF File]VA Form 9, APPEAL TO BOARD OF VETERANS' APPEALS
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(Number & Street or Post Office Box, City, State & ZIP Code) 7. IF I AM NOT THE VETERAN, MY NAME IS: (Last Name, First Name, Middle Initial) 8. THESE ARE THE ISSUES I WANT TO APPEAL TO THE BOARD: (Be sure to read the information about this block in paragraph 6 of the attached instructions.) A.
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[PDF File]FW-001 Request to Waive Court Fees
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If more than 6 people at home, add $460.42 for each extra person.
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[PDF File]REQUIRED: Please select a service type q FedEx Freight ...
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q FedEx Freight® Priority q FedEx Freight® Economy Shipper FXF Acct. # Attn. to Area Code Phone Number Address Address (Store, Dept., Ste., Flr., Apt., Div.) Address City State/Province ZIP/Postal Code Country Optional or Additional Service Fees and Charges Liftgate Inside Pickup Limited Access Shipper Bill of Lading # Special Instructions
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[PDF File]Form 911 Request for Taxpayer Advocate Service Assistance ...
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request to the TAS office in your state or city. You can find the fax number in the government listings in your local telephone directory, on our website at www.taxpayeradvocate.irs.gov, or in Publication 1546, Taxpayer Advocate Service - Your Voice at the IRS. • You also can mail this form.
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Baltimore city non emergency line