Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (2) - Systems Generated
Choice 1: become age
Choice 2: becomes age
Fill-in (3) - Systems Generated
Choice 1: 65
Choice 2: 65 and 2 months
Choice 3: 65 and 4 months
Choice 4: 65 and 6 months
Choice 5: 65 and 8 months
Choice 6: 65 and 10 months
Choice 7: 66
Choice 8: 66 and 2 months
Choice 9: 66 and 4 months
Choice 10: 66 and 6 months
Choice 11: 66 and 8 months
Choice 12: 66 and 10 months
Choice 13: 67
Fill-in (4) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) - Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (6) - Systems Generated
Choice 1: 65
Choice 2: 65 and 2 months
Choice 3: 65 and 4 months
Choice 4: 65 and 6 months
Choice 5: 65 and 8 months
Choice 6: 65 and 10 months
Choice 7: 66
Choice 8: 66 and 2 months
Choice 9: 66 and 4 months
Choice 10: 66 and 6 months
Choice 11: 66 and 8 months
Choice 12: 66 and 10 months
Choice 13: 67
Fill-in (7) - Systems Generated
MM/DD/CCYY