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