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f CHECK SHEET FOR DHTTRITUING PRESUMPTIVE ELIGIPILTEY
i FOR OLU—LGE INSURANCE
  ‘ Q , IEUQG ;
· (Social Security Account NSY
_ Addrsss of applicant:-.i_“..l__“_.______________“____________.__________________
, Q, Date of birth; Honth.___._,_____“________w_____ Day;________,_______Y€&r__________
:* 
Plac@_________N_________ _____________________ ____________________ _______________
A (City or Town) (@0uuty) (Stats) (Cnuntry) `
I I
Q E. * Rnccrd of Employment sincs D@c¤rb¤r Sl, 1336.
; Yams of Erplmysr mL&ir@EE of Pmilgyér -·* _ From 5; _E¤ --
?P—~· ~ —--- —s»—~~—·s V Month Year Month Y“&T
»   ""‘—`*"`”""`—‘"""""""*‘*’*"‘ "—“"""‘*‘""""""·——‘"**‘*‘*—_"‘”""‘“”‘*"`°""`_""
I _..,_.............____________________________________“_____..i...i.......-.-»~»—
s Q. il?—;§rricd, Etatgitiigwsi;Ei€EE“EE?£,   ©r“EEsb5md’s nano,
` age, and dsts of birth.
l Tame;____________“_____________________“__ M.Aqe_w"~_______Dst@ of Flrth...~.
5. Arc there snv childrsn imcluiime st@¤cril@r@r and lr allv adn ted childrsm,
J J r y l,   .,
under l? years cf sgc and unmarriei? if sc, haw wary?
" *· tt ’*‘****T""‘* ‘
(LFS or rn) _
F. Has &pplic&¤t previously filcd at ajillcgtion {wr any benefits u¤&sr Titls TT nf
the S crgisll Sw #;;¤rj_‘L;y .irct‘?____ ________________ __ If 5 c ’ 5 t ntf; t};¤ ;3 ¤_r_r> uprlrwr rib i ch th?
(Yes ir To}
application was filsi, the aptrstimmte dstc filci, and tkz rlacs wH¤rc filpi.
(U&mG5 . (Data ztyligdtlbn Eilzij —tCity§ J”¤¢~ (3T&tT5
1 *A wage earner attaining age 65 hcfers July 1, l?éOJ may qualify for wowtklv
t bGH€Fit5 Up¤H acqwiring six quarters of zmvwruge, Xmwevery if Lv attiinéd &KF
65 prior to January l, 1957, rcrmnsration paid to him wrior t¤ Jswuirv E, T9 ·‘.· ”, _
is not crintsd toward benefits, and ne quarter of covcrrgé va: b¤ 2¤¤#ir¤@ @*V·
in; this nerimi. Thsrnfmre, only the cwplmysrs ?~r wh¤w_h¤ s.*4r crkni sm ¤¤& ¤fV*F
January l, lQ33, should he imcluind,
If thé WQQE ¤&rm@r attaincd aqf QH in l?$7 or l9E£, rczuusratinh y2i” t° K*“
Sutssquent t¤ attainment Of age GE and prigr tn January 1, lQ3Q, is rwt Wag'?
ahi is ¤¤t cnuntzd toward b@n©fjts, Th¤r2f0r©, mann: at tht G:wZ0y*r$ fOr iV'
. péficd bctwcsn the wage earner'; sixty-fifth birthday and January l, 1739, F%**1“
not be in0l;&s&, V
YF£.F©rm SGS Supplsmért
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