TN 7 (10-16)
WDW005 REQUEST TO WITHDRAW APPLICATION APPROVED (B79)
(Requested)
Caption: Your Benefits
(1) asked to withdraw (2) application for benefits filed (3) . We have approved this request and (4) may disregard the previous certificate of award we sent (5) . (6) not entitled to the benefits described on this award certificate. (7) may withdraw a retirement application only once in (8) lifetime.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: You have
Choice 2: Beneficiary's name has
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Requested As A Year In Format Shown Below MM/DD/CCYY date application
filed
Fill-in (4) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6) - Systems Generated
Choice 1: You are
Choice 2: He is
Choice 3: She is
Fill-in (7) Systems Generated
Choice 1: You
Choice 2: He
Choice 3: She
Fill-in (8) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
WDW017 (C14) CANCELATION
(Requested)
Caption: Your Benefits
After (1) had requested that we withdraw (2) claim, (3) asked us to cancel this request. We are approving the cancellation.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she