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7* <br />DOLLAR AMOUNT PAWiENT <br />OR PERCENT OF DATE <br />TOTAL BENEFIT <br />1st Year <br />2nd Year <br />3rd Year <br />(No more than one payment per calendar year permitted) <br />Applic'ant <br />Social Security No. <br />Dated and received by and on behalf of the Association, this- <br />I * <br />day of 19 16 <br />Authorized Representative <br />APPLICATION BY ONE NOT A SEPARATED MEMBER <br />If separated member reached the age of fifty (50) years and <br />died within thirty (30) days thereafter, without making applica- <br />tion for his benefits, please fill in the preceding sections of <br />the form and the following: <br />Applicant's name <br />Applicant's address <br />What is your relationship to the deceased? <br />If spouse, date and place of marriage? <br />� 2 - <br />