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Date of Birth:
Life Expectancy:  
Current Marital Status (Answer Only The Questions That Pertain to Your Current Marital Status):
 Married
Your Spouse's Information:

First Name:  Last Name:

Date of Birth:

Life Expectancy:   
 Divorced
Former Spouse's Information:

First Name:  Last Name:

Date of Birth:

Former Spouse Currently Collecting Social Security Benefits?  

Have You Been Divorced For at Least 2 Years? Yes  No

Life Expectancy:    
 Survivor
Deceased Spouse's Information:

First Name:  Last Name:

Date of Birth:

Date of Death:

Prior to Death, Was Your Deceased Spouse Collecting Social Security Benefits?  

 Single