Fill-ins:
(1) “your”/Beneficiary's Name possessive
(2) 7 percent/15 percent/28 percent/31 percent/null
(3) “withheld”/null
(4) “beginning”/“for”/null
(5) Date in the format September 1995/null
(6) “and”/“through”/null
(7) Date in the format September 1995/null
(8) “,”/and/null
(9) 7 percent/15 percent/28 percent/31 percent/null
(10) “withheld”/null
(11) “beginning”/“for”/null
(12) Date in the format September 1995/null
(13) “and”/“through”/null
(14) Date in the format September 1995/null
(15) “and”/null
(16) 7 percent/15 percent/28 percent/31 percent/null
(17) “withheld”/null
(18) “beginning”/null
(19) Date in the format September 1995/null