MRSAP DEATH INFORMATION CHECKSHEET

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Information on this page is subject to the provisions of

 the Privacy Act of 1947 and will be protected accordingly.

****** DECEDENT ******

DATE CONTACTED:                 REPORTED BY:                  CAR�S INITIALS:______

LAST NAME:                       FIRST:                          MIDDLE: _______________             

*RANK:                 SSAN:                        DATE RETIRED:             SERVICE:  ______ 

DATE OF BIRTH:                              PLACE OF BIRTH:______________________________   

DATE OF DEATH:                             PLACE OF DEATH:________________________________

CAUSE OF DEATH (UNCONFIRMED):  ___________________________________________________

****** SURVIVOR ******

PNOK:                                               RELATIONSHIP: ______________________________

SSAN:                               PLACE OF MARRIAGE:  ______________________________________

DATE OF BIRTH:                       PLACE OF BIRTH: ____________________________________

LOCAL ADDRESS: _____________________________________________________________________________

HOME PHONE:                       __        WORK PHONE: ____________________________________

STATE OF LEGAL RESIDENCE: ______________________________________________________________

****** ADDITIONAL INFORMATION ******

SBP:                                     DRAPES:                                              DEERS:   ______________

_{(YES/NO)                                     (YES/NO)                          (CAR INITIALS)}

ELIGIBLE CHILDREN:________________________________________________________________________

_{(NAME, SSAN, AGE, DOB, ADDRESS � Attach extra sheets if necessary)}

PARENTS:                   LIVING: (Name and address, if alive)

___________________________________________________________________________________________________

_______________________________________________________________________________________

REMARKS: ____________________________________________________________________________________

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MRSAP Form 1                                       15 September 2002                                             Page 1 of 1