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Section A
Identification & Household
Names, dates, residence, dependents.
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Servicemember
Servicemember
Preferred name
Legal first name
Legal last name
Date of birth
SSN – last 4 only
We never collect full SSNs.
State of legal residence
Select…
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Phone
Email
U.S. citizen
Yes
Spouse (if applicable)
Spouse
Preferred name
Legal first name
Legal last name
Date of birth
SSN – last 4 only
We never collect full SSNs.
State of legal residence
Select…
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Phone
Email
U.S. citizen
Yes
Mailing address
Joint
Address line 1
Address line 2 (optional)
City
State
Select…
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP
Household
Joint
Marital status
Select…
single
married
separated
divorced
widowed
engaged
Number of dependents
Both household members are U.S. citizens
Yes
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