Apple Reference & Presentation Library 8 (Internal Edition)

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MacBinary | 1989-11-27 | 22.8 KB | [STCK/KCFM]
open in:
MacOS 8.1 extracted |
Win98 extracted |
DOS extracted
view JSON data |
view as text

This file was processed as: MacBinary (archive/macBinary).

You can browse this item here: Family Status Change
Confidence	Program	Detection	Match Type	Support
`10%`	dexvert	MacBinary `(archive/macBinary)`	fallback	Supported
`100%`	file	MacBinary II, inited, Wed Nov 8 04:09:34 1989, modified Mon Nov 27 09:29:03 1989, creator 'KCFM', type 'STCK', 22108 bytes "Family Status Change" , at 0x56dc 906 bytes resource	default (weak)
`99%`	file	data	default
`66%`	TrID	raw Group 3 FAX bitmap	default (weak)
`33%`	TrID	MacBinary 2	default (weak)
`100%`	siegfried	fmt/1762 MacBinary (II)	default
`100%`	lsar	MacBinary	default
id metadata
key	value
macFileType	`[STCK]`
macFileCreator	`[KCFM]`
hex view
+--------+-------------------------+-------------------------+--------+--------+
|00000000| 00 14 46 61 6d 69 6c 79 | 20 53 74 61 74 75 73 20 |..Family| Status |
|00000010| 43 68 61 6e 67 65 00 00 | 00 00 00 00 00 00 00 00 |Change..|........|
|00000020| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000030| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000040| 00 53 54 43 4b 4b 43 46 | 4d 01 00 00 00 00 00 00 |.STCKKCF|M.......|
|00000050| 00 00 00 00 00 56 5c 00 | 00 03 8a a1 7d 9d ce a1 |.....V\.|....}...|
|00000060| 96 f5 2f 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |../.....|........|
|00000070| 00 00 00 00 00 00 00 00 | 00 00 81 81 63 31 00 00 |........|....c1..|
|00000080| 00 0c 00 02 00 00 00 30 | 00 00 32 6a 00 00 01 de |.......0|..2j....|
|00000090| 00 00 2d 3c 00 00 2d 3e | 00 00 54 2a 00 00 00 00 |..-<..->|..T*....|
|000000a0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000000b0| 09 90 0c 60 00 01 00 01 | 00 00 00 00 00 01 00 00 |...`....|........|
|000000c0| 00 00 00 00 00 03 00 01 | 00 00 00 03 00 00 00 48 |........|.......H|
|000000d0| 00 48 00 00 00 00 03 08 | 02 40 ff f8 ff ee 03 10 |.H......|.@......|
|000000e0| 02 52 03 47 05 28 03 fc | 00 02 00 00 00 48 00 48 |.R.G.(..|.....H.H|
|000000f0| 00 00 00 00 03 08 02 40 | 00 01 00 00 00 64 00 00 |.......@|.....d..|
|00000100| 00 01 00 01 01 01 00 00 | 00 01 27 0f 00 01 00 01 |........|..'.....|
|00000110| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 02 00 19 |........|........|
|00000120| 01 90 00 00 00 00 00 70 | 00 00 00 00 00 00 00 00 |.......p|........|
|00000130| 00 01 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000140| 00 00 00 00 01 2b 00 01 | 00 06 00 06 40 38 00 00 |.....+..|....@8..|
|00000150| 00 00 00 00 40 38 00 00 | 00 00 00 00 00 22 00 03 |....@8..|....."..|
|00000160| 00 01 00 01 00 00 00 03 | 01 26 01 26 00 3c 00 38 |........|.&.&.<.8|
|00000170| 00 01 00 14 00 01 00 0a | 00 01 5f da 00 00 00 15 |........|.._.....|
|00000180| 00 01 00 0c 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000190| 00 00 00 00 00 00 00 00 | 00 00 00 03 00 00 ff ff |........|........|
|000001a0| ff ff ff ff ff ff 00 01 | 00 01 00 4d e5 4e 00 4d |........|...M.N.M|
|000001b0| e5 54 00 4a 75 e8 00 4a | 75 e8 00 00 00 00 00 00 |.T.Ju..J|u.......|
|000001c0| 00 01 00 01 00 01 00 01 | 00 01 00 01 00 00 00 00 |........|........|
|000001d0| 00 00 00 01 00 00 00 00 | 00 00 00 00 00 00 00 90 |........|........|
|000001e0| 00 07 00 00 00 01 09 90 | 0c 60 00 20 00 48 0c 3d |........|.`. .H.=|
|000001f0| 09 45 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |.E......|........|
|00000200| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000210| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000220| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000230| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000240| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000250| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 03 |........|........|
|00000260| 00 00 00 34 00 24 00 4c | 0b d0 09 44 00 01 00 01 |...4.$.L|...D....|
|00000270| 00 03 00 01 ff ff ff ff | ff ff ff ff 00 00 00 00 |........|........|
|00000280| 00 00 00 00 00 00 00 01 | 00 28 00 28 00 28 00 28 |........|.(.(.(.(|
|00000290| 00 00 00 00 00 00 00 00 | 00 07 00 00 00 6c 00 38 |........|.....l.8|
|000002a0| 01 3c 00 a4 09 20 00 01 | 00 00 ff ff ff ff ff ff |.<... ..|........|
|000002b0| ff ff 00 01 00 00 00 00 | 00 00 00 02 00 38 01 3c |........|.....8.<|
|000002c0| 00 a4 09 20 00 00 00 00 | 00 14 00 0e 00 01 00 00 |... ....|........|
|000002d0| 00 03 00 03 00 01 00 18 | 43 48 41 4e 47 45 20 4f |........|CHANGE O|
|000002e0| 46 20 46 41 4d 49 4c 59 | 20 53 54 41 54 55 53 0d |F FAMILY| STATUS.|
|000002f0| 00 00 00 16 00 01 00 00 | 00 00 00 0f 00 0c 00 14 |........|........|
|00000300| 01 00 00 0e 00 00 00 00 | 00 00 00 0d 00 00 00 cc |........|........|
|00000310| 00 5c 00 94 00 d0 00 fc | 00 00 00 00 00 00 00 00 |.\......|........|
|00000320| 00 00 00 02 00 07 00 00 | 00 56 00 5c 00 94 00 d0 |........|.V.\....|
|00000330| 00 fa 00 01 00 00 ff ff | ff ff ff ff ff ff 00 01 |........|........|
|00000340| 00 00 00 00 00 00 00 02 | 00 5c 00 94 00 d0 00 fa |........|.\......|
|00000350| 00 00 00 00 00 14 00 18 | 00 00 00 00 00 03 00 03 |........|........|
|00000360| 00 01 00 01 f0 ff 00 00 | 00 16 00 01 00 00 00 00 |........|........|
|00000370| 00 18 00 12 00 14 00 00 | 00 18 00 00 00 00 00 00 |........|........|
|00000380| 00 07 00 00 00 56 00 a1 | 00 df 00 ba 00 fc 00 01 |.....V..|........|
|00000390| 00 00 ff ff ff ff ff ff | ff ff 00 01 00 00 00 00 |........|........|
|000003a0| 00 00 00 02 00 a1 00 df | 00 ba 00 fc 00 00 00 00 |........|........|
|000003b0| 00 14 00 04 00 00 00 00 | 00 03 00 03 00 01 00 01 |........|........|
|000003c0| a8 00 00 00 00 16 00 01 | 00 00 00 00 00 05 00 04 |........|........|
|000003d0| 00 14 00 00 00 04 00 00 | 00 00 00 00 00 01 00 00 |........|........|
|000003e0| 00 ac 00 b1 07 dc 01 41 | 09 20 00 01 00 00 00 00 |.......A|. ......|
|000003f0| 00 15 00 00 00 0c 00 00 | 00 03 00 03 00 00 00 01 |........|........|
|00000400| 00 03 00 01 00 00 00 03 | 00 01 ff ff ff ff ff ff |........|........|
|00000410| ff ff 00 00 00 00 00 00 | 00 00 00 00 00 03 00 00 |........|........|
|00000420| ff ff ff ff ff ff ff ff | 00 90 00 90 00 3c 00 34 |........|.....<.4|
|00000430| 00 00 00 f4 00 02 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|00000440| 00 00 00 00 00 00 00 00 | 00 02 00 b2 07 dd 00 ed |........|........|
|00000450| 09 20 01 01 01 01 00 14 | 00 0a 00 80 00 00 00 03 |. ......|........|
|00000460| 00 03 00 01 00 0d 45 4d | 50 4c 4f 59 45 45 20 20 |......EM|PLOYEE  |
|00000470| 4e 4f 2e 00 00 00 00 16 | 00 01 00 00 00 00 00 0c |NO......|........|
|00000480| 00 09 00 14 00 00 00 0a | 00 00 00 00 00 00 00 01 |........|........|
|00000490| 00 00 00 a2 00 b1 06 98 | 01 41 07 dc 00 01 00 00 |........|.A......|
|000004a0| 00 00 00 15 00 00 00 0c | 00 00 00 03 00 03 00 00 |........|........|
|000004b0| 00 01 00 03 00 01 00 00 | 00 03 00 01 ff ff ff ff |........|........|
|000004c0| ff ff ff ff 00 00 00 00 | 00 00 00 00 00 00 00 03 |........|........|
|000004d0| 00 00 ff ff ff ff ff ff | ff ff 00 88 00 88 00 3c |........|.......<|
|000004e0| 00 38 00 00 00 f5 00 01 | 00 01 00 00 00 00 00 00 |.8......|........|
|000004f0| 00 00 00 00 00 00 00 00 | 00 00 00 02 00 b2 06 99 |........|........|
|00000500| 00 ed 07 dc 01 01 01 01 | 00 14 00 0a 00 80 00 00 |........|........|
|00000510| 00 03 00 03 00 01 00 04 | 44 41 54 45 00 00 00 16 |........|DATE....|
|00000520| 00 01 00 00 00 00 00 0c | 00 09 00 14 00 00 00 0a |........|........|
|00000530| 00 00 00 00 00 00 00 01 | 00 00 00 a8 01 41 04 df |........|.....A..|
|00000540| 01 d1 05 de 00 01 00 00 | 00 00 00 15 00 00 00 0c |........|........|
|00000550| 00 00 00 03 00 03 00 00 | 00 01 00 03 00 01 00 00 |........|........|
|00000560| 00 03 00 01 ff ff ff ff | ff ff ff ff 00 00 00 00 |........|........|
|00000570| 00 00 00 00 00 00 00 03 | 00 00 ff ff ff ff ff ff |........|........|
|00000580| ff ff 00 90 00 90 00 3c | 00 34 00 00 00 f6 00 06 |.......<|.4......|
|00000590| 00 01 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000005a0| 00 00 00 02 01 42 04 e0 | 01 7d 05 de 01 01 01 01 |.....B..|.}......|
|000005b0| 00 14 00 0a 00 80 00 00 | 00 03 00 03 00 01 00 0a |........|........|
|000005c0| 4d 41 49 4c 20 20 53 54 | 4f 50 00 00 00 16 00 01 |MAIL  ST|OP......|
|000005d0| 00 00 00 00 00 0c 00 09 | 00 14 00 00 00 0a 00 00 |........|........|
|000005e0| 00 00 00 00 00 01 00 00 | 00 a8 01 41 07 dc 01 d1 |........|...A....|
|000005f0| 09 20 00 01 00 00 00 00 | 00 15 00 20 00 0c 00 00 |. ......|... ....|
|00000600| 00 03 00 03 00 00 00 01 | 00 03 00 01 00 00 00 03 |........|........|
|00000610| 00 01 ff ff ff ff ff ff | ff ff 00 00 00 00 00 00 |........|........|
|00000620| 00 00 00 00 00 03 00 00 | ff ff ff ff ff ff ff ff |........|........|
|00000630| 00 94 00 94 00 3c 00 38 | 00 00 00 f7 00 08 00 01 |.....<.8|........|
|00000640| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000650| 00 02 01 42 07 dd 01 7d | 09 20 01 01 01 01 00 14 |...B...}|. ......|
|00000660| 00 0a 00 80 00 00 00 03 | 00 03 00 01 00 09 41 50 |........|......AP|
|00000670| 50 4c 45 4c 49 4e 4b 31 | 00 00 00 16 00 01 00 00 |PLELINK1|........|
|00000680| 00 00 00 0c 00 09 00 14 | 00 00 00 0a 00 00 00 00 |........|........|
|00000690| 00 00 00 01 00 00 00 ac | 01 41 05 de 01 d1 07 dc |........|.A......|
|000006a0| 00 01 00 00 00 00 00 15 | 00 00 00 0c 00 00 00 03 |........|........|
|000006b0| 00 03 00 01 00 01 00 03 | 00 01 00 00 00 03 00 01 |........|........|
|000006c0| ff ff ff ff ff ff ff ff | 00 00 00 00 00 00 00 00 |........|........|
|000006d0| 00 00 00 03 00 00 ff ff | ff ff ff ff ff ff 00 90 |........|........|
|000006e0| 00 90 00 3c 00 34 00 00 | 00 f8 00 07 00 01 00 00 |...<.4..|........|
|000006f0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 02 |........|........|
|00000700| 01 42 05 df 01 7d 07 dc | 01 01 01 01 00 14 00 0a |.B...}..|........|
|00000710| 00 80 00 00 00 03 00 03 | 00 01 00 0e 54 45 4c 45 |........|....TELE|
|00000720| 50 48 4f 4e 45 20 20 4e | 4f 2e 00 00 00 16 00 01 |PHONE  N|O.......|
|00000730| 00 00 00 00 00 0c 00 09 | 00 14 00 00 00 0a 00 00 |........|........|
|00000740| 00 00 00 00 00 01 00 00 | 00 a6 01 41 03 49 01 d1 |........|...A.I..|
|00000750| 04 14 00 01 00 00 00 00 | 00 15 00 00 00 0c 00 00 |........|........|
|00000760| 00 03 00 03 00 00 00 01 | 00 03 00 01 00 00 00 03 |........|........|
|00000770| 00 01 ff ff ff ff ff ff | ff ff 00 00 00 00 00 00 |........|........|
|00000780| 00 00 00 00 00 03 00 00 | ff ff ff ff ff ff ff ff |........|........|
|00000790| 00 70 00 70 00 3c 00 34 | 00 00 00 f9 00 04 00 01 |.p.p.<.4|........|
|000007a0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000007b0| 00 02 01 42 03 4a 01 7d | 04 14 01 01 01 01 00 14 |...B.J.}|........|
|000007c0| 00 0a 00 80 00 00 00 03 | 00 03 00 01 00 08 44 49 |........|......DI|
|000007d0| 56 2e 20 4e 4f 2e 00 00 | 00 16 00 01 00 00 00 00 |V. NO...|........|
|000007e0| 00 0c 00 09 00 14 00 00 | 00 0a 00 00 00 00 00 00 |........|........|
|000007f0| 00 01 00 00 00 a8 01 41 | 04 14 01 d1 04 df 00 01 |.......A|........|
|00000800| 00 00 00 00 00 15 00 00 | 00 0c 00 00 00 03 00 03 |........|........|
|00000810| 00 00 00 01 00 03 00 01 | 00 00 00 03 00 01 ff ff |........|........|
|00000820| ff ff ff ff ff ff 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000830| 00 03 00 00 ff ff ff ff | ff ff ff ff 00 90 00 90 |........|........|
|00000840| 00 3c 00 34 00 00 00 fa | 00 05 00 01 00 00 00 00 |.<.4....|........|
|00000850| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 02 01 42 |........|.......B|
|00000860| 04 15 01 7d 04 df 01 01 | 01 01 00 14 00 0a 00 80 |...}....|........|
|00000870| 00 00 00 03 00 03 00 01 | 00 09 44 45 50 54 2e 20 |........|..DEPT. |
|00000880| 4e 4f 2e 5f 00 00 00 16 | 00 01 00 00 00 00 00 0c |NO._....|........|
|00000890| 00 09 00 14 00 00 00 0a | 00 00 00 00 00 00 00 01 |........|........|
|000008a0| 00 00 00 ac 01 41 00 70 | 01 d1 03 49 00 01 00 00 |.....A.p|...I....|
|000008b0| 00 00 00 15 00 00 00 0c | 00 00 00 03 00 03 00 2a |........|.......*|
|000008c0| 00 01 00 03 00 01 00 00 | 00 03 00 01 ff ff ff ff |........|........|
|000008d0| ff ff ff ff 00 00 00 00 | 00 00 00 00 00 00 00 03 |........|........|
|000008e0| 00 00 ff ff ff ff ff ff | ff ff 01 98 01 98 00 3c |........|.......<|
|000008f0| 00 38 00 00 00 fb 00 03 | 00 01 00 00 00 00 00 00 |.8......|........|
|00000900| 00 00 00 00 00 00 00 00 | 00 00 00 02 01 42 00 71 |........|.....B.q|
|00000910| 01 7d 03 49 01 01 01 01 | 00 14 00 0a 00 80 00 00 |.}.I....|........|
|00000920| 00 03 00 03 00 01 00 0e | 45 4d 50 4c 4f 59 45 45 |........|EMPLOYEE|
|00000930| 20 20 4e 41 4d 45 00 00 | 00 16 00 01 00 00 00 00 |  NAME..|........|
|00000940| 00 0c 00 09 00 14 00 00 | 00 0a 00 00 00 00 00 00 |........|........|
|00000950| 00 02 00 00 00 22 00 b1 | 07 dc 00 ee 07 dc 00 01 |....."..|........|
|00000960| 00 00 00 03 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000970| 00 00 00 00 00 00 00 00 | 00 02 00 00 00 22 01 40 |........|.....".@|
|00000980| 07 dc 01 7e 07 dc 00 01 | 00 00 00 03 00 00 00 00 |...~....|........|
|00000990| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000009a0| 00 02 00 00 00 22 01 3e | 05 de 01 7c 05 de 00 01 |.....".>|...|....|
|000009b0| 00 00 00 03 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000009c0| 00 00 00 00 00 00 00 00 | 00 02 00 00 00 22 01 40 |........|.....".@|
|000009d0| 04 de 01 7e 04 de 00 01 | 00 00 00 03 00 00 00 00 |...~....|........|
|000009e0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000009f0| 00 02 00 00 00 22 01 3e | 04 14 01 7c 04 14 00 01 |.....".>|...|....|
|00000a00| 00 00 00 03 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000a10| 00 00 00 00 00 00 00 00 | 00 02 00 00 00 22 01 3e |........|.....".>|
|00000a20| 03 48 01 7c 03 48 00 01 | 00 00 00 03 00 00 00 00 |.H.|.H..|........|
|00000a30| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000a40| 00 07 00 00 00 68 0b f4 | 00 4c 0c 3c 02 38 00 01 |.....h..|.L.<.8..|
|00000a50| 00 01 ff ff ff ff ff ff | ff ff 00 01 00 00 00 00 |........|........|
|00000a60| 00 00 00 02 0b f4 00 4c | 0c 3c 02 38 00 00 00 00 |.......L|.<.8....|
|00000a70| 00 14 00 0e 00 20 00 00 | 00 01 00 03 00 01 00 14 |..... ..|........|
|00000a80| 41 70 70 6c 65 20 43 6f | 6d 70 75 74 65 72 2c 20 |Apple Co|mputer, |
|00000a90| 49 6e 63 2e 00 00 00 16 | 00 01 00 00 00 00 00 0f |Inc.....|........|
|00000aa0| 00 0c 00 14 20 00 00 0e | 00 00 00 00 00 00 00 07 |.... ...|........|
|00000ab0| 00 00 00 62 0b f4 08 1c | 0c 3c 09 44 00 01 00 00 |...b....|.<.D....|
|00000ac0| ff ff ff ff ff ff ff ff | 00 01 00 00 00 00 00 00 |........|........|
|00000ad0| 00 02 0b f4 08 1c 0c 3c | 09 44 00 00 00 00 00 14 |.......<|.D......|
|00000ae0| 00 0a 00 00 00 00 00 02 | 00 03 00 01 00 0e 42 45 |........|......BE|
|00000af0| 4e 35 30 30 20 28 31 31 | 2f 38 39 29 00 00 00 16 |N500 (11|/89)....|
|00000b00| 00 01 00 00 00 00 00 0c | 00 09 00 14 00 00 00 0a |........|........|
|00000b10| 00 00 00 00 00 00 00 01 | 00 00 00 ae 01 d1 03 48 |........|.......H|
|00000b20| 02 60 09 1f 00 01 00 00 | 00 00 00 15 00 00 00 0c |.`......|........|
|00000b30| 00 00 00 03 00 03 00 00 | 00 01 00 03 00 01 00 00 |........|........|
|00000b40| 00 03 00 01 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000b50| 00 00 00 00 00 00 00 03 | 00 00 ff ff ff ff ff ff |........|........|
|00000b60| ff ff 01 98 01 98 00 3c | 00 38 00 00 01 00 00 0a |.......<|.8......|
|00000b70| 00 01 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000b80| 00 00 00 02 01 d2 03 49 | 02 0d 09 1f 01 01 01 01 |.......I|........|
|00000b90| 00 14 00 0a 00 00 00 00 | 00 03 00 03 00 01 00 10 |........|........|
|00000ba0| 20 20 57 4f 52 4b 20 20 | 4c 4f 43 41 54 49 4f 4e |  WORK  |LOCATION|
|00000bb0| 00 00 00 16 00 01 00 00 | 00 00 00 0c 00 09 00 14 |........|........|
|00000bc0| 00 00 00 0a 00 00 00 00 | 00 00 00 01 00 00 00 be |........|........|
|00000bd0| 01 d1 00 70 02 60 03 49 | 00 01 00 00 00 00 00 15 |...p.`.I|........|
|00000be0| 00 00 00 0c 00 00 00 03 | 00 03 00 00 00 01 00 03 |........|........|
|00000bf0| 00 01 00 00 00 03 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|00000c00| 00 00 00 00 00 00 00 00 | 00 00 00 03 00 00 ff ff |........|........|
|00000c10| ff ff ff ff ff ff 01 98 | 01 98 00 3c 00 38 00 00 |........|...<.8..|
|00000c20| 01 01 00 09 00 01 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000c30| 00 00 00 00 00 00 00 02 | 01 d2 00 71 02 0d 03 49 |........|...q...I|
|00000c40| 01 01 01 01 00 14 00 0a | 00 00 00 00 00 03 00 03 |........|........|
|00000c50| 00 01 00 1f 45 4d 50 2e | 20 20 20 20 53 4f 43 49 |....EMP.|    SOCI|
|00000c60| 41 4c 20 20 20 53 45 43 | 55 52 49 54 59 20 20 20 |AL   SEC|URITY   |
|00000c70| 4e 4f 2e 69 00 00 00 16 | 00 01 00 00 00 00 00 0c |NO.i....|........|
|00000c80| 00 09 00 14 00 00 00 0a | 00 00 00 00 00 00 00 01 |........|........|
|00000c90| 00 00 00 a2 0b 03 06 df | 0b 93 08 8f 00 01 00 00 |........|........|
|00000ca0| 00 00 00 15 00 00 00 0c | 00 00 00 03 00 02 00 00 |........|........|
|00000cb0| 00 01 00 05 00 00 00 00 | 00 04 00 01 00 00 00 00 |........|........|
|00000cc0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 03 |........|........|
|00000cd0| 00 00 ff ff ff ff ff ff | ff ff 00 d4 00 d4 00 14 |........|........|
|00000ce0| 00 3c 00 00 01 02 00 00 | 00 00 00 00 00 00 00 00 |.<......|........|
|00000cf0| 00 00 00 00 00 00 00 00 | 00 00 00 02 0b 57 06 df |........|.....W..|
|00000d00| 0b 94 08 90 00 01 81 81 | 00 14 00 0a 00 00 00 00 |........|........|
|00000d10| 00 03 00 01 00 01 00 04 | 44 41 54 45 00 00 00 16 |........|DATE....|
|00000d20| 00 01 00 00 00 00 00 0c | 00 09 00 14 00 00 00 0a |........|........|
|00000d30| 00 00 00 00 00 00 00 01 | 00 00 00 a8 0b 03 01 07 |........|........|
|00000d40| 0b 93 05 87 00 01 00 00 | 00 00 00 15 00 00 00 0c |........|........|
|00000d50| 00 00 00 03 00 02 00 0a | 00 01 00 05 00 00 00 00 |........|........|
|00000d60| 00 04 00 01 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000d70| 00 00 00 00 00 00 00 03 | 00 00 ff ff ff ff ff ff |........|........|
|00000d80| ff ff 00 d4 00 d4 00 14 | 00 3c 00 00 01 03 00 00 |........|.<......|
|00000d90| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00000da0| 00 00 00 02 0b 57 01 07 | 0b 94 05 88 00 01 81 81 |.....W..|........|
|00000db0| 00 14 00 0a 00 00 00 00 | 00 03 00 01 00 01 00 09 |........|........|
|00000dc0| 53 49 47 4e 41 54 55 52 | 45 20 00 00 00 16 00 01 |SIGNATUR|E ......|
|00000dd0| 00 00 00 00 00 0c 00 09 | 00 14 00 00 00 0a 00 00 |........|........|
|00000de0| 00 00 00 00 00 07 00 00 | 01 44 08 4f 00 87 09 21 |........|.D.O...!|
|00000df0| 09 06 00 01 00 00 ff ff | ff ff ff ff ff ff 00 01 |........|........|
|00000e00| 00 00 00 00 00 00 00 02 | 08 4f 00 87 09 21 09 06 |........|.O...!..|
|00000e10| 00 00 00 00 00 14 00 0c | ff 00 00 00 00 01 00 02 |........|........|
|00000e20| 00 04 00 db 43 55 53 54 | 4f 4d 20 43 4f 56 45 52 |....CUST|OM COVER|
|00000e30| 41 47 45 20 41 43 43 4f | 55 4e 54 0d 0d 42 61 73 |AGE ACCO|UNT..Bas|
|00000e40| 65 64 20 6f 6e 20 74 68 | 65 20 61 62 6f 76 65 20 |ed on th|e above |
|00000e50| 66 61 6d 69 6c 79 20 73 | 74 61 74 75 73 20 63 68 |family s|tatus ch|
|00000e60| 61 6e 67 65 2c 20 49 20 | 77 6f 75 6c 64 20 6c 69 |ange, I |would li|
|00000e70| 6b 65 20 74 6f 20 65 6e | 72 6f 6c 6c 20 69 6e 20 |ke to en|roll in |
|00000e80| 6f 72 20 6d 61 6b 65 20 | 61 20 63 68 61 6e 67 65 |or make |a change|
|00000e90| 20 74 6f 20 6d 79 20 48 | 65 61 6c 74 68 20 43 61 | to my H|ealth Ca|
|00000ea0| 72 65 20 61 6e 64 20 2f | 20 6f 72 20 44 65 70 65 |re and /| or Depe|
|00000eb0| 6e 64 65 6e 74 20 43 61 | 72 65 20 41 63 63 6f 75 |ndent Ca|re Accou|
|00000ec0| 6e 74 20 61 73 20 66 6f | 6c 6c 6f 77 73 20 20 28 |nt as fo|llows  (|
|00000ed0| 43 6f 6e 74 72 69 62 75 | 74 69 6f 6e 20 63 68 61 |Contribu|tion cha|
|00000ee0| 6e 67 65 73 20 6d 75 73 | 74 20 62 65 20 69 6e 20 |nges mus|t be in |
|00000ef0| 77 68 6f 6c 65 20 64 6f | 6c 6c 61 72 73 29 3a 5f |whole do|llars):_|
|00000f00| 00 00 00 2a 00 02 00 00 | 00 00 00 0c 00 09 00 14 |...*....|........|
|00000f10| 01 00 00 0c 00 00 00 00 | 00 00 00 00 00 17 00 0c |........|........|
|00000f20| 00 09 00 14 00 00 00 0c | 00 00 00 00 00 00 00 07 |........|........|
|00000f30| 00 00 01 56 0a 7d 00 87 | 0a f1 09 0e 00 01 00 00 |...V.}..|........|
|00000f40| ff ff ff ff ff ff ff ff | 00 01 00 00 00 00 00 00 |........|........|
|00000f50| 00 02 0a 7d 00 87 0a f1 | 09 0e 00 00 00 00 00 14 |...}....|........|
|00000f60| 00 0c ff 00 00 02 00 01 | 00 02 00 02 00 c5 31 2e |........|......1.|
|00000f70| 20 20 49 20 61 75 74 68 | 6f 72 69 7a 65 20 74 68 |  I auth|orize th|
|00000f80| 65 20 61 62 6f 76 65 20 | 63 68 61 6e 67 65 20 6f |e above |change o|
|00000f90| 66 20 63 6f 76 65 72 61 | 67 65 20 61 6e 64 20 61 |f covera|ge and a|
|00000fa0| 6e 79 20 72 65 71 75 69 | 72 65 64 20 70 61 79 72 |ny requi|red payr|
|00000fb0| 6f 6c 6c 20 64 65 64 75 | 63 74 69 6f 6e 73 2e 0d |oll dedu|ctions..|
|00000fc0| 32 2e 20 20 49 20 75 6e | 64 65 72 73 74 61 6e 64 |2.  I un|derstand|
|00000fd0| 20 74 68 61 74 20 74 68 | 65 20 61 62 6f 76 65 20 | that th|e above |
|00000fe0| 63 68 61 6e 67 65 20 28 | 73 29 20 77 69 6c 6c 20 |change (|s) will |
|00000ff0| 72 65 6d 61 69 6e 20 69 | 6e 20 65 66 66 65 63 74 |remain i|n effect|
|00001000| 20 75 6e 74 69 6c 20 49 | 20 63 68 61 6e 67 65 20 | until I| change |
|00001010| 74 68 65 6d 20 69 6e 20 | 61 63 63 6f 72 64 61 6e |them in |accordan|
|00001020| 63 65 20 77 69 74 68 20 | 70 6c 61 6e 20 72 75 6c |ce with |plan rul|
|00001030| 65 73 2e 20 00 00 00 52 | 00 04 00 00 00 00 00 0c |es. ...R|........|
|00001040| 00 09 00 14 01 00 00 0c | 00 00 00 00 00 00 00 00 |........|........|
|00001050| 00 02 00 0c 00 09 00 14 | 00 00 00 0c 00 00 00 00 |........|........|
|00001060| 00 00 00 00 00 52 00 0c | 00 09 00 14 01 00 00 0c |.....R..|........|
|00001070| 00 00 00 00 00 00 00 00 | 00 54 00 0c 00 09 00 14 |........|.T......|
|00001080| 00 00 00 0c 00 00 00 00 | 00 00 00 01 00 00 00 aa |........|........|
|00001090| 06 01 00 93 06 6d 03 63 | 00 01 00 00 00 00 00 15 |.....m.c|........|
|000010a0| 00 00 00 0c 00 00 00 03 | 00 02 00 00 00 01 00 05 |........|........|
|000010b0| 00 00 00 00 00 04 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|000010c0| 00 00 00 00 00 00 00 00 | 00 00 00 03 00 00 ff ff |........|........|
|000010d0| ff ff ff ff ff ff 01 68 | 01 68 00 30 00 30 00 00 |.......h|.h.0.0..|
|000010e0| 01 0c 00 1a 00 01 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000010f0| 00 00 00 00 00 00 00 02 | 06 3d 00 93 06 6e 03 64 |........|.=...n.d|
|00001100| 00 01 81 81 00 14 00 0a | 00 00 00 00 00 03 00 01 |........|........|
|00001110| 00 01 00 0c 43 55 52 52 | 45 4e 54 20 50 4c 41 4e |....CURR|ENT PLAN|
|00001120| 00 00 00 16 00 01 00 00 | 00 00 00 0c 00 09 00 14 |........|........|
|00001130| 00 00 00 0a 00 00 00 00 | 00 00 00 01 00 00 00 ac |........|........|
|00001140| 06 01 03 af 06 6d 06 1f | 00 01 00 00 00 00 00 15 |.....m..|........|
|00001150| 00 00 00 0c 00 00 00 03 | 00 02 00 00 00 01 00 05 |........|........|
|00001160| 00 00 00 00 00 04 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|00001170| 00 00 00 00 00 00 00 00 | 00 00 00 03 00 00 ff ff |........|........|
|00001180| ff ff ff ff ff ff 01 68 | 01 68 00 30 00 30 00 00 |.......h|.h.0.0..|
|00001190| 01 0d 00 1b 00 01 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000011a0| 00 00 00 00 00 00 00 02 | 06 3d 03 af 06 6e 06 20 |........|.=...n. |
|000011b0| 00 01 81 81 00 14 00 0a | 00 00 00 00 00 03 00 01 |........|........|
|000011c0| 00 01 00 0d 4d 41 52 52 | 49 41 47 45 20 44 41 54 |....MARR|IAGE DAT|
|000011d0| 45 00 00 00 00 16 00 01 | 00 00 00 00 00 0c 00 09 |E.......|........|
|000011e0| 00 14 00 00 00 0a 00 00 | 00 00 00 00 00 01 00 00 |........|........|
|000011f0| 00 ae 06 01 06 a4 06 6d | 08 fb 00 01 00 00 00 00 |.......m|........|
|00001200| 00 15 00 00 00 0c 00 00 | 00 03 00 02 00 00 00 01 |........|........|
|00001210| 00 05 00 00 00 00 00 04 | 00 01 00 00 00 00 00 00 |........|........|
|00001220| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 03 00 00 |........|........|
|00001230| ff ff ff ff ff ff ff ff | 01 68 01 68 00 30 00 30 |........|.h.h.0.0|
|00001240| 00 00 01 0e 00 1c 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|00001250| 00 00 00 00 00 00 00 00 | 00 02 06 3d 06 a4 06 6e |........|...=...n|
|00001260| 08 fc 00 01 81 81 00 14 | 00 0a 00 00 00 00 00 03 |........|........|
|00001270| 00 01 00 01 00 0f 4c 4f | 41 20 52 45 54 55 52 4e |......LO|A RETURN|
|00001280| 20 44 41 54 45 00 00 00 | 00 16 00 01 00 00 00 00 | DATE...|........|
|00001290| 00 0c 00 09 00 14 00 00 | 00 0a 00 00 00 00 00 00 |........|........|
|000012a0| 00 07 00 00 00 a6 04 71 | 00 93 04 b9 07 6b 00 01 |.......q|.....k..|
|000012b0| 00 00 ff ff ff ff ff ff | ff ff 00 01 00 00 00 00 |........|........|
|000012c0| 00 00 00 02 04 71 00 93 | 04 b9 07 6b 00 00 00 00 |.....q..|...k....|
|000012d0| 00 14 00 00 ff 00 00 00 | 00 01 00 02 00 01 00 29 |........|.......)|
|000012e0| 52 45 41 53 4f 4e 20 46 | 4f 52 20 43 48 41 4e 47 |REASON F|OR CHANG|
|000012f0| 45 20 20 20 43 68 65 63 | 6b 20 61 70 70 72 6f 70 |E   Chec|k approp|
|00001300| 72 69 61 74 65 20 62 6f | 78 00 00 00 00 3e 00 03 |riate bo|x....>..|
|00001310| 00 00 00 00 00 0c 00 09 | 00 14 01 00 00 0c 00 00 |........|........|
|00001320| 00 00 00 00 00 00 00 11 | 00 0f 00 0c 00 14 01 00 |........|........|
|00001330| 00 0e 00 00 00 00 00 00 | 00 00 00 14 00 0f 00 0c |........|........|
|00001340| 00 14 00 00 00 0e 00 00 | 00 00 00 00 00 01 00 00 |........|........|
|00001350| 00 b6 04 70 05 2c 04 d4 | 08 94 00 01 00 00 00 00 |...p.,..|........|
|00001360| 00 15 00 00 00 0c 00 00 | 00 03 00 03 00 00 00 01 |........|........|
|00001370| 00 04 00 00 00 00 00 04 | 00 01 00 00 00 00 00 00 |........|........|
|00001380| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 03 00 00 |........|........|
|00001390| ff ff ff ff ff ff ff ff | 01 98 02 5c 00 34 00 30 |........|...\.4.0|
|000013a0| 00 00 01 0f 00 12 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|000013b0| 00 00 00 00 00 00 00 00 | 00 02 04 70 06 38 04 d5 |........|...p.8..|
|000013c0| 08 95 01 00 81 81 00 14 | 00 0c 00 00 00 00 00 01 |........|........|
|000013d0| 00 03 00 01 00 18 45 66 | 66 65 63 74 69 76 65 20 |......Ef|fective |
|000013e0| 44 61 74 65 20 6f 66 20 | 43 68 61 6e 67 65 00 00 |Date of |Change..|
|000013f0| 00 16 00 01 00 00 00 00 | 00 0c 00 09 00 14 00 00 |........|........|
|00001400| 00 0c 00 00 00 00 00 00 | 00 07 00 00 00 a2 02 c3 |........|........|
|00001410| 00 93 03 0b 06 cb 00 01 | 00 00 ff ff ff ff ff ff |........|........|
|00001420| ff ff 00 01 00 00 00 00 | 00 00 00 02 02 c3 00 93 |........|........|
|00001430| 03 0b 06 cb 00 00 00 00 | 00 14 00 00 ff 00 00 00 |........|........|
|00001440| 00 01 00 02 00 01 00 26 | 54 59 50 45 20 4f 46 20 |.......&|TYPE OF |
|00001450| 43 48 41 4e 47 45 20 20 | 20 43 68 65 63 6b 20 61 |CHANGE  | Check a|
|00001460| 70 70 72 6f 70 72 69 61 | 74 65 20 62 6f 78 00 00 |ppropria|te box..|
|00001470| 00 3e 00 03 00 00 00 00 | 00 0c 00 09 00 14 01 00 |.>......|........|
|00001480| 00 0c 00 00 00 00 00 00 | 00 00 00 0e 00 0f 00 0c |........|........|
|00001490| 00 14 01 00 00 0e 00 00 | 00 00 00 00 00 00 00 11 |........|........|
|000014a0| 00 0f 00 0c 00 14 00 00 | 00 0e 00 00 00 00 00 00 |........|........|
|000014b0| 00 01 00 00 00 ca 03 21 | 00 93 03 69 04 83 00 01 |.......!|...i....|
|000014c0| 00 00 00 00 00 15 00 00 | 00 0c 00 00 00 03 00 03 |........|........|
|000014d0| 00 01 00 01 00 04 00 00 | 00 00 00 00 00 01 00 00 |........|........|
|000014e0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000014f0| 00 03 00 00 ff ff ff ff | ff ff ff ff 00 28 03 ac |........|.....(..|
|00001500| 00 14 00 20 00 00 01 10 | 00 0b 00 01 00 00 00 00 |... ....|........|
|00001510| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 02 03 21 |........|.......!|
|00001520| 00 d7 03 6a 04 84 01 00 | 81 81 00 14 00 0c 00 00 |...j....|........|
|00001530| 00 00 00 01 00 03 00 01 | 00 2b 4e 61 6d 65 20 43 |........|.+Name C|
|00001540| 68 61 6e 67 65 2e 20 20 | 28 43 68 61 6e 67 65 20 |hange.  |(Change |
|00001550| 74 6f 20 74 68 61 74 20 | 73 68 6f 77 6e 20 61 62 |to that |shown ab|
|00001560| 6f 76 65 2e 29 1a 00 00 | 00 16 00 01 00 00 00 00 |ove.)...|........|
|00001570| 00 0c 00 09 00 14 00 00 | 00 0c 00 00 00 00 00 00 |........|........|
|00001580| 00 01 00 00 00 b2 03 2c | 04 9b 03 69 09 04 00 01 |.......,|...i....|
|00001590| 00 00 00 00 00 15 00 00 | 00 0c 00 00 00 03 00 03 |........|........|
|000015a0| 02 aa 00 01 00 02 00 00 | 00 00 00 04 00 01 00 00 |........|........|
|000015b0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000015c0| 00 03 00 00 ff ff ff ff | ff ff ff ff 01 d4 01 28 |........|.......(|
|000015d0| 00 14 00 29 00 00 01 11 | 00 0c 00 01 00 00 00 00 |...)....|........|
|000015e0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 02 03 2c |........|.......,|
|000015f0| 04 9b 03 6a 06 6f 01 01 | 81 80 00 14 00 0c 00 00 |...j.o..|........|
|00001600| 00 00 00 03 00 03 00 01 | 00 14 20 20 4d 79 20 66 |........|..  My f|
|00001610| 6f 72 6d 65 72 20 6e 61 | 6d 65 20 77 61 73 00 00 |ormer na|me was..|
|00001620| 00 16 00 01 00 00 00 00 | 00 0c 00 09 00 14 00 00 |........|........|
|00001630| 00 0c 00 00 00 00 00 00 | 00 01 00 00 00 ba 03 91 |........|........|
|00001640| 00 93 03 d9 03 3f 00 01 | 00 00 00 00 00 15 00 00 |.....?..|........|
|00001650| 00 0c 00 00 00 03 00 03 | 00 01 00 01 00 04 00 00 |........|........|
|00001660| 00 00 00 00 00 01 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001670| 00 00 00 00 00 00 00 00 | 00 03 00 00 ff ff ff ff |........|........|
|00001680| ff ff ff ff 00 28 02 68 | 00 14 00 20 00 00 01 12 |.....(.h|... ....|
|00001690| 00 0d 00 01 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000016a0| 00 00 00 00 00 02 03 91 | 00 d7 03 da 03 40 01 00 |........|.....@..|
|000016b0| 81 81 00 14 00 0c 00 00 | 00 00 00 01 00 03 00 01 |........|........|
|000016c0| 00 1c 41 64 64 20 44 65 | 70 65 6e 64 65 6e 74 73 |..Add De|pendents|
|000016d0| 20 4c 69 73 74 65 64 20 | 62 65 6c 6f 77 20 00 00 | Listed |below ..|
|000016e0| 00 16 00 01 00 00 00 00 | 00 0c 00 09 00 14 00 00 |........|........|
|000016f0| 00 0c 00 00 00 00 00 00 | 00 01 00 00 00 bc 03 91 |........|........|
|00001700| 04 c3 03 d9 07 97 00 01 | 00 00 00 00 00 15 00 00 |........|........|
|00001710| 00 0c 00 00 00 03 00 03 | 00 01 00 01 00 04 00 00 |........|........|
|00001720| 00 00 00 00 00 01 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001730| 00 00 00 00 00 00 00 00 | 00 03 00 00 ff ff ff ff |........|........|
|00001740| ff ff ff ff 00 28 02 90 | 00 14 00 20 00 00 01 13 |.....(..|... ....|
|00001750| 00 0e 00 01 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001760| 00 00 00 00 00 02 03 91 | 05 07 03 da 07 98 01 00 |........|........|
|00001770| 81 81 00 14 00 0c 00 00 | 00 00 00 01 00 03 00 01 |........|........|
|00001780| 00 1e 44 65 6c 65 74 65 | 20 44 65 70 65 6e 64 65 |..Delete| Depende|
|00001790| 6e 74 73 20 4c 69 73 74 | 65 64 20 42 65 6c 6f 77 |nts List|ed Below|
|000017a0| 00 00 00 16 00 01 00 00 | 00 00 00 0c 00 09 00 14 |........|........|
|000017b0| 00 00 00 0c 00 00 00 00 | 00 00 00 01 00 00 00 bc |........|........|
|000017c0| 03 fd 00 93 04 45 03 7f | 00 01 00 00 00 00 00 15 |.....E..|........|
|000017d0| 00 00 00 0c 00 00 00 03 | 00 03 00 01 00 01 00 04 |........|........|
|000017e0| 00 00 00 00 00 00 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|000017f0| 00 00 00 00 00 00 00 00 | 00 00 00 03 00 00 ff ff |........|........|
|00001800| ff ff ff ff ff ff 00 28 | 02 a8 00 14 00 20 00 00 |.......(|..... ..|
|00001810| 01 14 00 0f 00 01 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001820| 00 00 00 00 00 00 00 02 | 03 fd 00 d7 04 46 03 80 |........|.....F..|
|00001830| 01 00 81 81 00 14 00 0c | 00 00 00 00 00 01 00 03 |........|........|
|00001840| 00 01 00 1e 43 75 73 74 | 6f 6d 20 43 6f 76 65 72 |....Cust|om Cover|
|00001850| 61 67 65 20 61 63 63 6f | 75 6e 74 20 63 68 61 6e |age acco|unt chan|
|00001860| 67 65 00 00 00 16 00 01 | 00 00 00 00 00 0c 00 09 |ge......|........|
|00001870| 00 14 00 00 00 0c 00 00 | 00 00 00 00 00 01 00 00 |........|........|
|00001880| 00 c8 09 d7 05 50 0a 43 | 09 1f 00 01 00 00 00 00 |.....P.C|........|
|00001890| 00 15 00 00 00 0c 00 00 | 00 03 00 02 00 84 00 01 |........|........|
|000018a0| 00 05 00 00 00 00 00 04 | 00 01 00 00 00 00 00 00 |........|........|
|000018b0| 00 00 00 00 00 00 00 00 | 00 00 00 03 00 03 00 00 |........|........|
|000018c0| ff ff ff ff ff ff ff ff | 01 68 01 68 00 30 00 30 |........|.h.h.0.0|
|000018d0| 00 00 01 15 00 21 00 01 | 00 00 00 00 00 00 00 00 |.....!..|........|
|000018e0| 00 00 00 00 00 00 00 00 | 00 02 0a 13 05 50 0a 44 |........|.....P.D|
|000018f0| 09 20 00 01 81 81 00 14 | 00 0a 00 20 00 00 00 03 |. ......|... ....|
|00001900| 00 01 00 01 00 2a 54 4f | 54 41 4c 20 44 45 50 45 |.....*TO|TAL DEPE|
|00001910| 4e 44 45 4e 54 20 43 41 | 52 45 20 43 4f 4e 54 52 |NDENT CA|RE CONTR|
|00001920| 49 42 55 54 49 4f 4e 20 | 50 45 52 20 57 45 45 4b |IBUTION |PER WEEK|
|00001930| 00 00 00 16 00 01 00 00 | 00 00 00 0c 00 09 00 14 |........|........|
|00001940| 20 00 00 0a 00 00 00 00 | 00 00 00 01 00 00 00 a8 | .......|........|
|00001950| 09 d7 02 1b 0a 17 05 1e | 00 01 00 00 00 00 00 15 |........|........|
|00001960| 00 00 00 0c 00 00 00 03 | 00 02 00 00 00 01 00 04 |........|........|
|00001970| 00 00 00 00 00 04 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|00001980| 00 00 00 00 00 00 00 00 | 00 00 00 03 00 00 ff ff |........|........|
|00001990| ff ff ff ff ff ff 01 14 | 01 08 00 24 00 24 00 00 |........|...$.$..|
|000019a0| 01 16 00 20 00 01 00 00 | 00 00 00 00 00 00 00 00 |... ....|........|
|000019b0| 00 00 00 00 00 00 00 02 | 09 d7 04 16 0a 18 05 1f |........|........|
|000019c0| 01 00 81 81 00 14 00 0a | 00 00 00 00 00 01 00 02 |........|........|
|000019d0| 00 01 00 09 44 45 44 55 | 43 54 49 4f 4e 01 00 00 |....DEDU|CTION...|
|000019e0| 00 16 00 01 00 00 00 00 | 00 0c 00 09 00 14 00 00 |........|........|
|000019f0| 00 0a 00 00 00 00 00 00 | 00 07 00 00 00 64 09 cb |........|.....d..|
|00001a00| 00 93 0a 17 02 17 00 01 | 00 00 ff ff ff ff ff ff |........|........|
|00001a10| ff ff 00 01 00 00 00 00 | 00 00 00 02 09 cb 00 93 |........|........|
|00001a20| 0a 17 02 17 00 00 00 00 | 00 14 00 0a 00 00 00 00 |........|........|
|00001a30| 00 01 00 02 00 01 00 0f | 44 45 50 45 4e 44 45 4e |........|DEPENDEN|
|00001a40| 54 20 43 41 52 45 3a 00 | 00 00 00 16 00 01 00 00 |T CARE:.|........|
|00001a50| 00 00 00 0c 00 09 00 14 | 00 00 00 0a 00 00 00 00 |........|........|
|00001a60| 00 00 00 07 00 00 00 6e | 0a 17 02 12 0a 57 04 1e |.......n|.....W..|
|00001a70| 00 01 00 00 ff ff ff ff | ff ff ff ff 00 01 00 00 |........|........|
|00001a80| 00 00 00 00 00 02 0a 17 | 02 12 0a 57 04 1e 00 00 |........|...W....|
|00001a90| 00 00 00 14 00 0c 00 00 | 00 00 00 03 00 01 00 01 |........|........|
|00001aa0| 00 1a 49 6e 63 72 65 61 | 73 65 2c 20 44 65 63 72 |..Increa|se, Decr|
|00001ab0| 65 61 73 65 20 6f 72 20 | 53 74 6f 70 00 00 00 16 |ease or |Stop....|
|00001ac0| 00 01 00 00 00 00 00 0c | 00 09 00 14 00 00 00 0c |........|........|
|00001ad0| 00 00 00 00 00 00 00 01 | 00 00 00 c6 09 3d 05 50 |........|.....=.P|
|00001ae0| 09 a9 09 1f 00 01 00 00 | 00 00 00 15 00 00 00 0c |........|........|
|00001af0| 00 00 00 03 00 02 00 84 | 00 01 00 05 00 00 00 00 |........|........|
|00001b00| 00 04 00 01 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001b10| 00 00 00 00 00 03 00 03 | 00 00 ff ff ff ff ff ff |........|........|
|00001b20| ff ff 01 68 01 68 00 30 | 00 30 00 00 01 17 00 1f |...h.h.0|.0......|
|00001b30| 00 01 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001b40| 00 00 00 02 09 79 05 50 | 09 aa 09 20 00 01 81 81 |.....y.P|... ....|
|00001b50| 00 14 00 0a 00 20 00 00 | 00 03 00 01 00 01 00 27 |..... ..|.......'|
|00001b60| 54 4f 54 41 4c 20 48 45 | 41 4c 54 48 20 43 41 52 |TOTAL HE|ALTH CAR|
|00001b70| 45 20 43 4f 4e 54 52 49 | 42 55 54 49 4f 4e 20 50 |E CONTRI|BUTION P|
|00001b80| 45 52 20 57 45 45 4b ff | 00 00 00 16 00 01 00 00 |ER WEEK.|........|
|00001b90| 00 00 00 0c 00 09 00 14 | 20 00 00 0a 00 00 00 00 |........| .......|
|00001ba0| 00 00 00 01 00 00 00 a8 | 09 3b 01 d3 09 7f 05 02 |........|.;......|
|00001bb0| 00 01 00 00 00 00 00 15 | 00 00 00 0c 00 00 00 03 |........|........|
|00001bc0| 00 02 00 00 00 01 00 04 | 00 00 00 00 00 04 00 01 |........|........|
|00001bd0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001be0| 00 00 00 03 00 00 ff ff | ff ff ff ff ff ff 01 14 |........|........|
|00001bf0| 01 20 00 24 00 24 00 00 | 01 18 00 1e 00 01 00 00 |. .$.$..|........|
|00001c00| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 02 |........|........|
|00001c10| 09 3b 03 e2 09 80 05 03 | 01 00 81 81 00 14 00 0a |.;......|........|
|00001c20| 00 00 00 00 00 01 00 02 | 00 01 00 09 44 45 44 55 |........|....DEDU|
|00001c30| 43 54 49 4f 4e 00 00 00 | 00 16 00 01 00 00 00 00 |CTION...|........|
|00001c40| 00 0c 00 09 00 14 00 00 | 00 0a 00 00 00 00 00 00 |........|........|
|00001c50| 00 07 00 00 00 6a 09 7b | 01 b6 09 bb 03 c2 00 01 |.....j.{|........|
|00001c60| 00 00 ff ff ff ff ff ff | ff ff 00 01 00 00 00 00 |........|........|
|00001c70| 00 00 00 02 09 7b 01 b6 | 09 bb 03 c2 00 00 00 00 |.....{..|........|
|00001c80| 00 14 00 0c 00 00 00 00 | 00 03 00 03 00 01 00 15 |........|........|
|00001c90| 4e 65 77 2c 20 43 68 61 | 6e 67 65 20 6f 72 20 43 |New, Cha|nge or C|
|00001ca0| 61 6e 63 65 6c 6d 00 00 | 00 16 00 01 00 00 00 00 |ancelm..|........|
|00001cb0| 00 0c 00 09 00 14 00 00 | 00 0c 00 00 00 00 00 00 |........|........|
|00001cc0| 00 07 00 00 00 60 09 2b | 00 93 09 7f 01 cf 00 01 |.....`.+|........|
|00001cd0| 00 00 ff ff ff ff ff ff | ff ff 00 01 00 00 00 00 |........|........|
|00001ce0| 00 00 00 02 09 2b 00 93 | 09 7f 01 cf 00 00 00 00 |.....+..|........|
|00001cf0| 00 14 00 0a 00 00 00 00 | 00 01 00 02 00 01 00 0c |........|........|
|00001d00| 48 45 41 4c 54 48 20 43 | 41 52 45 3a 00 00 00 16 |HEALTH C|ARE:....|
|00001d10| 00 01 00 00 00 00 00 0c | 00 09 00 14 00 00 00 0a |........|........|
|00001d20| 00 00 00 00 00 00 00 01 | 00 00 00 b0 04 fd 02 e3 |........|........|
|00001d30| 05 45 04 a7 00 01 00 00 | 00 00 00 15 00 00 00 0c |.E......|........|
|00001d40| 00 00 00 03 00 03 00 01 | 00 01 00 04 00 00 00 00 |........|........|
|00001d50| 00 00 00 01 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001d60| 00 00 00 00 00 00 00 03 | 00 00 ff ff ff ff ff ff |........|........|
|00001d70| ff ff 00 28 01 80 00 14 | 00 20 00 00 01 19 00 15 |...(....|. ......|
|00001d80| 00 01 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001d90| 00 00 00 02 04 fd 03 27 | 05 46 04 a8 01 00 81 81 |.......'|.F......|
|00001da0| 00 14 00 0c 00 00 00 00 | 00 01 00 03 00 01 00 11 |........|........|
|00001db0| 43 68 61 6e 67 65 20 6f | 66 20 43 75 73 74 6f 64 |Change o|f Custod|
|00001dc0| 79 00 00 00 00 16 00 01 | 00 00 00 00 00 0c 00 09 |y.......|........|
|00001dd0| 00 14 00 00 00 0c 00 00 | 00 00 00 00 00 01 00 00 |........|........|
|00001de0| 00 a6 04 fd 00 93 05 45 | 01 c5 00 01 00 00 00 00 |.......E|........|
|00001df0| 00 15 00 00 00 0c 00 00 | 00 03 00 03 00 01 00 01 |........|........|
|00001e00| 00 04 00 00 00 00 00 00 | 00 01 00 00 00 00 00 00 |........|........|
|00001e10| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 03 00 00 |........|........|
|00001e20| ff ff ff ff ff ff ff ff | 00 28 00 e4 00 14 00 20 |........|.(..... |
|00001e30| 00 00 01 1a 00 13 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|00001e40| 00 00 00 00 00 00 00 00 | 00 02 04 fd 00 e1 05 46 |........|.......F|
|00001e50| 01 c6 01 00 81 81 00 14 | 00 0c 00 00 00 00 00 01 |........|........|
|00001e60| 00 03 00 01 00 08 4d 61 | 72 72 69 61 67 65 00 00 |......Ma|rriage..|
|00001e70| 00 16 00 01 00 00 00 00 | 00 0c 00 09 00 14 00 00 |........|........|
|00001e80| 00 0c 00 00 00 00 00 00 | 00 01 00 00 00 ae 05 6d |........|.......m|
|00001e90| 04 d3 05 b5 06 97 00 01 | 00 00 00 00 00 15 00 00 |........|........|
|00001ea0| 00 0c 00 00 00 03 00 03 | 00 01 00 01 00 04 00 00 |........|........|
|00001eb0| 00 00 00 00 00 01 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001ec0| 00 00 00 00 00 00 00 00 | 00 03 00 00 ff ff ff ff |........|........|
|00001ed0| ff ff ff ff 00 28 01 80 | 00 14 00 20 00 00 01 1b |.....(..|... ....|
|00001ee0| 00 19 00 01 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00001ef0| 00 00 00 00 00 02 05 6d | 05 17 05 b6 06 98 01 00 |.......m|........|
|00001f00| 81 81 00 14 00 0c 00 00 | 00 00 00 01 00 03 00 01 |........|........|
|00001f10| 00 10 4e 65 77 62 6f 72 | 6e 2f 41 64 6f 70 74 69 |..Newbor|n/Adopti|
|00001f20| 6f 6e 00 00 00 16 00 01 | 00 00 00 00 00 0c 00 09 |on......|........|
|00001f30| 00 14 00 00 00 0c 00 00 | 00 00 00 00 00 01 00 00 |........|........|
|00001f40| 00 c6 05 6d 00 95 05 c0 | 04 85 00 01 00 00 00 00 |...m....|........|
|00001f50| 00 15 00 00 00 0c 00 00 | 00 03 00 03 00 01 00 01 |........|........|
|00001f60| 00 04 00 00 00 00 00 00 | 00 01 00 00 00 00 00 00 |........|........|
|00001f70| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 03 00 00 |........|........|
|00001f80| ff ff ff ff ff ff ff ff | 00 28 03 a4 00 14 00 20 |........|.(..... |
|00001f90| 00 00 01 1c 00 18 00 01 | 00 00 00 00 00 00 00 00 |........|........|
|00001fa0| 00 00 00 00 00 00 00 00 | 00 02 05 6d 00 e1 05 c1 |........|...m....|
|00001fb0| 04 86 01 00 81 81 00 14 | 00 0c 00 00 00 00 00 01 |........|........|
|00001fc0| 00 03 00 01 00 28 4c 6f | 73 73 2f 43 6f 6d 6d 65 |.....(Lo|ss/Comme|
|00001fd0| 6e 63 65 6d 65 6e 74 20 | 6f 66 20 53 70 6f 75 73 |ncement |of Spous|
|00001fe0| 65 27 73 20 45 6d 70 6c | 6f 79 6d 65 6e 74 00 00 |e's Empl|oyment..|
|00001ff0| 00 16 00 01 00 00 00 00 | 00 0c 00 09 00 14 00 00 |........|........|
|00002000| 00 0c 00 00 00 00 00 00 | 00 01 00 00 00 a6 04 fd |........|........|
|00002010| 01 ca 05 45 02 df 00 01 | 00 00 00 00 00 15 00 00 |...E....|........|
|00002020| 00 0c 00 00 00 03 00 03 | 00 01 00 01 00 04 00 00 |........|........|
|00002030| 00 00 00 00 00 01 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00002040| 00 00 00 00 00 00 00 00 | 00 03 00 00 ff ff ff ff |........|........|
|00002050| ff ff ff ff 00 28 00 c4 | 00 14 00 20 00 00 01 1d |.....(..|... ....|
|00002060| 00 14 00 01 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00002070| 00 00 00 00 00 02 04 fd | 02 1b 05 46 02 e0 01 00 |........|...F....|
|00002080| 81 81 00 14 00 0c 00 00 | 00 00 00 01 00 03 00 01 |........|........|
|00002090| 00 07 44 69 76 6f 72 63 | 65 00 00 00 00 16 00 01 |..Divorc|e.......|
|000020a0| 00 00 00 00 00 0c 00 09 | 00 14 00 00 00 0c 00 00 |........|........|
|000020b0| 00 00 00 00 00 01 00 00 | 00 a4 04 fd 04 d3 05 3f |........|.......?|
|000020c0| 05 ab 00 01 00 00 00 00 | 00 15 00 00 00 0c 00 00 |........|........|
|000020d0| 00 03 00 03 00 01 00 01 | 00 04 00 00 00 00 00 00 |........|........|
|000020e0| 00 01 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000020f0| 00 00 00 00 00 03 00 00 | ff ff ff ff ff ff ff ff |........|........|
|00002100| 00 28 00 98 00 14 00 20 | 00 00 01 1e 00 16 00 01 |.(..... |........|
|00002110| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00002120| 00 02 04 fd 05 13 05 40 | 05 ac 01 00 81 81 00 14 |.......@|........|
|00002130| 00 0c 00 00 00 00 00 01 | 00 03 00 01 00 05 44 65 |........|......De|
|00002140| 61 74 68 00 00 00 00 16 | 00 01 00 00 00 00 00 0c |ath.....|........|
|00002150| 00 09 00 14 00 00 00 0c | 00 00 00 00 00 00 00 01 |........|........|
|00002160| 00 00 00 c0 04 fd 05 d7 | 05 45 08 fb 00 01 00 00 |........|.E......|
|00002170| 00 00 00 15 00 00 00 0c | 00 00 00 03 00 03 00 01 |........|........|
|00002180| 00 01 00 04 00 00 00 00 | 00 00 00 01 00 00 00 00 |........|........|
|00002190| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 03 |........|........|
|000021a0| 00 00 ff ff ff ff ff ff | ff ff 00 28 02 e0 00 14 |........|...(....|
|000021b0| 00 20 00 00 01 1f 00 17 | 00 01 00 00 00 00 00 00 |. ......|........|
|000021c0| 00 00 00 00 00 00 00 00 | 00 00 00 02 04 fd 06 1b |........|........|
|000021d0| 05 46 08 fc 01 00 81 81 | 00 14 00 0c 00 00 00 00 |.F......|........|
|000021e0| 00 01 00 03 00 01 00 22 | 43 68 61 6e 67 65 20 69 |......."|Change i|
|000021f0| 6e 20 44 65 70 65 6e 64 | 65 6e 74 20 53 74 75 64 |n Depend|ent Stud|
|00002200| 65 6e 74 20 53 74 61 74 | 75 73 00 00 00 16 00 01 |ent Stat|us......|
|00002210| 00 00 00 00 00 0c 00 09 | 00 14 00 00 00 0c 00 00 |........|........|
|00002220| 00 00 00 00 00 02 00 00 | 00 22 06 d5 03 13 07 13 |........|."......|
|00002230| 03 13 00 01 00 00 00 03 | 00 00 00 00 00 00 00 00 |........|........|
|00002240| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 02 00 00 |........|........|
|00002250| 00 22 06 d5 04 fb 07 13 | 04 fb 00 01 00 00 00 03 |."......|........|
|00002260| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00002270| 00 00 00 00 00 02 00 00 | 00 22 06 d4 05 7b 07 12 |........|."...{..|
|00002280| 05 7b 00 01 00 00 00 03 | 00 00 00 00 00 00 00 00 |.{......|........|
|00002290| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 02 00 00 |........|........|
|000022a0| 00 22 06 d4 06 5b 07 12 | 06 5b 00 01 00 00 00 03 |."...[..|.[......|
|000022b0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000022c0| 00 00 00 00 00 02 00 00 | 00 22 06 d4 07 3b 07 12 |........|."...;..|
|000022d0| 07 3b 00 01 00 00 00 03 | 00 00 00 00 00 00 00 00 |.;......|........|
|000022e0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 02 00 00 |........|........|
|000022f0| 00 22 06 d4 08 1b 07 12 | 08 1b 00 01 00 00 00 03 |."......|........|
|00002300| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00002310| 00 00 00 00 00 08 00 00 | 05 f4 06 83 00 93 08 33 |........|.......3|
|00002320| 08 fb 00 01 00 00 00 00 | 00 03 00 00 00 03 00 00 |........|........|
|00002330| 00 00 00 01 00 01 00 03 | 00 00 ff ff ff ff ff ff |........|........|
|00002340| ff ff 00 01 00 00 00 00 | 00 00 00 00 00 00 00 60 |........|.......`|
|00002350| 00 00 00 48 00 01 00 00 | 01 20 00 00 00 07 00 3c |...H....|. .....<|
|00002360| ff ff ff ff ff ff ff ff | ff ff ff ff ff ff ff ff |........|........|
|00002370| aa 55 aa 55 aa 55 aa 55 | 00 04 00 02 00 01 00 1d |.U.U.U.U|........|
|00002380| 00 01 08 58 00 00 00 00 | 00 00 00 00 00 00 00 00 |...X....|........|
|00002390| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 48 |........|.......H|
|000023a0| 00 02 06 84 00 94 06 bf | 08 fb 01 01 01 01 00 14 |........|........|
|000023b0| 00 0c 00 01 00 00 00 01 | 00 03 00 01 00 10 44 45 |........|......DE|
|000023c0| 50 45 4e 44 45 4e 54 20 | 43 48 41 4e 47 45 00 00 |PENDENT |CHANGE..|
|000023d0| 00 16 00 01 00 00 00 00 | 00 0c 00 09 00 14 01 00 |........|........|
|000023e0| 00 0c 00 00 00 00 00 00 | 00 07 03 80 00 1a 8d fc |........|........|
|000023f0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 ba ff e0 |........|........|
|00002400| 00 24 00 4f 02 3e 00 01 | 00 00 00 00 00 15 00 00 |.$.O.>..|........|
|00002410| 00 0c 00 00 00 03 00 03 | 04 2a 00 01 00 06 00 01 |........|.*......|
|00002420| 00 00 00 03 00 01 ff ff | ff ff ff ff ff ff 00 00 |........|........|
|00002430| 00 00 00 00 00 00 00 00 | 00 03 00 02 ff ff ff ff |........|........|
|00002440| ff ff ff ff 00 00 00 00 | 00 00 00 00 00 00 01 21 |........|.......!|
|00002450| 00 01 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00002460| 00 00 00 00 00 02 06 c0 | 00 94 07 1f 04 13 01 01 |........|........|
|00002470| 01 01 00 14 00 0a 00 80 | 00 00 00 03 00 03 00 01 |........|........|
|00002480| 00 1c 4c 41 53 54 20 4e | 41 4d 45 2c 20 46 49 52 |..LAST N|AME, FIR|
|00002490| 53 54 20 4e 41 4d 45 20 | 26 20 4d 2e 49 2e 00 00 |ST NAME |& M.I...|
|000024a0| 00 16 00 01 00 00 00 00 | 00 0c 00 09 00 14 00 00 |........|........|
|000024b0| 00 0a 00 00 00 00 00 00 | 00 80 00 1a 8e 24 00 00 |........|.....$..|
|000024c0| 00 00 00 00 00 00 00 00 | 00 00 00 a2 ff e0 01 04 |........|........|
|000024d0| 00 4c 02 3e 00 01 00 00 | 00 00 00 15 00 00 00 0c |.L.>....|........|
|000024e0| 00 00 00 03 00 03 00 00 | 00 01 00 06 00 01 00 00 |........|........|
|000024f0| 00 03 00 01 ff ff ff ff | ff ff ff ff 00 00 00 00 |........|........|
|00002500| 00 00 00 00 00 00 00 03 | 00 02 ff ff ff ff ff ff |........|........|
|00002510| ff ff 32 b2 00 1a 53 e8 | 00 1c 00 00 01 23 00 02 |..2...S.|.....#..|
|00002520| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00002530| 00 00 00 02 06 c0 04 14 | 07 1f 04 93 01 01 01 01 |........|........|
|00002540| 00 14 00 0a 00 80 00 00 | 00 03 00 03 00 01 00 03 |........|........|
|00002550| 53 45 58 39 00 00 00 16 | 00 01 00 00 00 00 00 0c |SEX9....|........|
|00002560| 00 09 00 14 00 00 00 0a | 00 00 00 00 00 00 00 e8 |........|........|
|00002570| 00 1a 8e 4c 00 00 00 00 | 00 00 00 00 00 00 00 00 |...L....|........|
|00002580| 00 a4 ff e0 01 3e 00 4c | 02 3e 00 01 00 00 00 00 |.....>.L|.>......|
|00002590| 00 15 00 00 00 0c 00 00 | 00 03 00 03 00 00 00 01 |........|........|
|000025a0| 00 06 00 01 00 00 00 03 | 00 01 ff ff ff ff ff ff |........|........|
|000025b0| ff ff 00 00 00 00 00 00 | 00 00 00 00 00 03 00 02 |........|........|
|000025c0| ff ff ff ff ff ff ff ff | 32 b2 00 1a 53 e8 00 1c |........|2...S...|
|000025d0| 00 00 01 2a 00 03 00 00 | 00 00 00 00 00 00 00 00 |...*....|........|
|000025e0| 00 00 00 00 00 00 00 00 | 00 02 06 c0 04 94 07 1f |........|........|
|000025f0| 05 7b 01 01 01 01 00 14 | 00 0a 00 80 00 00 00 03 |.{......|........|
|00002600| 00 03 00 01 00 05 42 49 | 52 54 48 0a 00 00 00 16 |......BI|RTH.....|
|00002610| 00 01 00 00 00 00 00 0c | 00 09 00 14 00 00 00 0a |........|........|
|00002620| 00 00 00 00 00 00 00 e0 | 00 1a 8e 74 00 00 00 00 |........|...t....|
|00002630| 00 00 00 00 00 00 00 00 | 00 a6 ff e0 01 5e 00 4c |........|.....^.L|
|00002640| 02 3e 00 01 00 00 00 00 | 00 15 00 00 00 0c 00 00 |.>......|........|
|00002650| 00 03 00 03 00 02 00 01 | 00 06 00 01 00 00 00 03 |........|........|
|00002660| 00 01 ff ff ff ff ff ff | ff ff 00 00 00 00 00 00 |........|........|
|00002670| 00 00 00 00 00 03 00 02 | ff ff ff ff ff ff ff ff |........|........|
|00002680| 32 b2 00 1a 53 e8 00 1c | 00 00 01 24 00 04 00 00 |2...S...|...$....|
|00002690| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000026a0| 00 02 06 c0 05 7c 07 1f | 06 5b 01 01 01 01 00 14 |.....|..|.[......|
|000026b0| 00 0a 00 80 00 00 00 03 | 00 03 00 01 00 07 4d 45 |........|......ME|
|000026c0| 44 49 43 41 4c 00 00 00 | 00 16 00 01 00 00 00 00 |DICAL...|........|
|000026d0| 00 0c 00 09 00 14 00 00 | 00 0a 00 00 00 00 00 00 |........|........|
|000026e0| 00 e0 00 1a 8e 9c 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000026f0| 00 00 00 a4 ff e0 01 96 | 00 4c 02 3e 00 01 00 00 |........|.L.>....|
|00002700| 00 00 00 15 00 00 00 0c | 00 00 00 03 00 03 00 02 |........|........|
|00002710| 00 01 00 06 00 01 00 00 | 00 03 00 01 ff ff ff ff |........|........|
|00002720| ff ff ff ff 00 00 00 00 | 00 00 00 00 00 00 00 03 |........|........|
|00002730| 00 02 ff ff ff ff ff ff | ff ff 32 b2 00 1a 53 e8 |........|..2...S.|
|00002740| 00 1c 00 00 01 25 00 05 | 00 00 00 00 00 00 00 00 |.....%..|........|
|00002750| 00 00 00 00 00 00 00 00 | 00 00 00 02 06 c0 06 5c |........|.......\|
|00002760| 07 1f 07 3b 01 01 01 01 | 00 14 00 0a 00 80 00 00 |...;....|........|
|00002770| 00 03 00 03 00 01 00 06 | 44 45 4e 54 41 4c 00 00 |........|DENTAL..|
|00002780| 00 16 00 01 00 00 00 00 | 00 0c 00 09 00 14 00 00 |........|........|
|00002790| 00 0a 00 00 00 00 00 00 | 00 e0 00 1a 8e c4 00 00 |........|........|
|000027a0| 00 00 00 00 00 00 00 00 | 00 00 00 a8 ff e0 01 4e |........|.......N|
|000027b0| 00 4c 01 be 00 01 00 00 | 00 00 00 15 00 00 00 0c |.L......|........|
|000027c0| 00 00 00 03 00 03 00 02 | 00 01 00 06 00 01 00 00 |........|........|
|000027d0| 00 03 00 01 ff ff ff ff | ff ff ff ff 00 00 00 00 |........|........|
|000027e0| 00 00 00 00 00 00 00 03 | 00 02 ff ff ff ff ff ff |........|........|
|000027f0| ff ff 32 b2 00 1a 53 e8 | 00 1c 00 00 01 26 00 06 |..2...S.|.....&..|
|00002800| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00002810| 00 00 00 02 06 c0 07 3c | 07 1f 08 1b 01 01 01 01 |.......<|........|
|00002820| 00 14 00 0a 00 80 00 00 | 00 03 00 03 00 01 00 09 |........|........|
|00002830| 44 45 50 2e 20 4c 49 46 | 45 00 00 00 00 16 00 01 |DEP. LIF|E.......|
|00002840| 00 00 00 00 00 0c 00 09 | 00 14 00 00 00 0a 00 00 |........|........|
|00002850| 00 00 00 00 00 e0 00 1a | 8e e8 00 00 00 00 00 00 |........|........|
|00002860| 00 00 00 00 00 00 00 a6 | ff e0 01 86 00 4c 01 be |........|.....L..|
|00002870| 00 01 00 00 00 00 00 15 | 00 00 00 0c 00 00 00 03 |........|........|
|00002880| 00 03 00 02 00 01 00 06 | 00 01 00 00 00 03 00 01 |........|........|
|00002890| ff ff ff ff ff ff ff ff | 00 00 00 00 00 00 00 00 |........|........|
|000028a0| 00 00 00 03 00 02 ff ff | ff ff ff ff ff ff 32 b2 |........|......2.|
|000028b0| 00 1a 53 e8 00 1c 00 00 | 01 27 00 07 00 00 00 00 |..S.....|.'......|
|000028c0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 02 |........|........|
|000028d0| 06 c0 08 1c 07 1f 08 fb | 01 01 01 01 00 14 00 0a |........|........|
|000028e0| 00 80 00 00 00 03 00 03 | 00 01 00 08 44 45 50 2e |........|....DEP.|
|000028f0| 41 44 26 44 00 00 00 16 | 00 01 00 00 00 00 00 0c |AD&D....|........|
|00002900| 00 09 00 14 00 00 00 0a | 00 00 00 00 00 00 00 02 |........|........|
|00002910| 00 00 00 22 06 bd 04 13 | 07 1f 04 13 00 01 00 00 |..."....|........|
|00002920| 00 03 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00002930| 00 00 00 00 00 00 00 02 | 00 00 00 22 06 bd 04 95 |........|..."....|
|00002940| 07 1f 04 95 00 01 00 00 | 00 03 00 00 00 00 00 00 |........|........|
|00002950| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 02 |........|........|
|00002960| 00 00 00 22 06 bc 05 7b | 07 1e 05 7b 00 01 00 00 |..."...{|...{....|
|00002970| 00 03 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00002980| 00 00 00 00 00 00 00 02 | 00 00 00 22 06 bd 06 5b |........|..."...[|
|00002990| 07 1f 06 5b 00 01 00 00 | 00 03 00 00 00 00 00 00 |...[....|........|
|000029a0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 02 |........|........|
|000029b0| 00 00 00 22 06 bc 07 3b | 07 1e 07 3b 00 01 00 00 |..."...;|...;....|
|000029c0| 00 03 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|000029d0| 00 00 00 00 00 00 00 02 | 00 00 00 22 06 bc 08 1b |........|..."....|
|000029e0| 07 1e 08 1b 00 01 00 00 | 00 03 00 00 00 00 00 00 |........|........|
|000029f0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 01 |........|........|
|00002a00| 00 00 00 be 03 fd 04 c3 | 04 68 06 b8 00 01 00 00 |........|.h......|
|00002a10| 00 00 00 15 00 00 00 0c | 00 00 00 03 00 03 00 01 |........|........|
|00002a20| 00 01 00 04 00 00 00 00 | 00 00 00 01 00 00 00 00 |........|........|
|00002a30| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 03 |........|........|
|00002a40| 00 00 ff ff ff ff ff ff | ff ff 00 28 01 b4 00 14 |........|...(....|
|00002a50| 00 20 00 00 01 28 00 10 | 00 01 00 00 00 00 00 00 |. ...(..|........|
|00002a60| 00 00 00 00 00 00 00 00 | 00 00 00 02 03 fd 05 04 |........|........|
|00002a70| 04 69 06 b9 01 00 81 81 | 00 14 00 0c 00 00 00 00 |.i......|........|
|00002a80| 00 01 00 03 00 02 00 1f | 4c 69 66 65 20 49 6e 73 |........|Life Ins|
|00002a90| 75 72 61 6e 63 65 20 0d | 43 6f 76 65 72 61 67 65 |urance .|Coverage|
|00002aa0| 20 43 68 61 6e 67 65 44 | 00 00 00 16 00 01 00 00 | ChangeD|........|
|00002ab0| 00 00 00 0c 00 09 00 14 | 00 00 00 0c 00 00 00 00 |........|........|
|00002ac0| 00 00 00 01 00 00 00 a4 | 03 e4 06 d8 04 74 09 04 |........|.....t..|
|00002ad0| 00 01 00 00 00 00 00 15 | 00 00 00 0c 00 00 00 03 |........|........|
|00002ae0| 00 02 00 00 00 01 00 05 | 00 00 00 00 00 04 00 01 |........|........|
|00002af0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00002b00| 00 02 00 03 00 00 ff ff | ff ff ff ff ff ff 00 9a |........|........|
|00002b10| 00 9a 00 3c 00 3c 00 00 | 01 29 00 11 00 01 00 00 |...<.<..|.)......|
|00002b20| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 02 |........|........|
|00002b30| 04 38 06 d8 04 75 09 05 | 00 01 81 81 00 14 00 0a |.8...u..|........|
|00002b40| 00 00 00 00 00 03 00 01 | 00 01 00 06 41 4d 4f 55 |........|....AMOU|
|00002b50| 4e 54 00 00 00 16 00 01 | 00 00 00 00 00 0c 00 09 |NT......|........|
|00002b60| 00 14 00 00 00 0a 00 00 | 00 00 00 00 00 07 00 00 |........|........|
|00002b70| 00 82 0b 98 04 88 0b cb | 07 d4 00 01 00 00 ff ff |........|........|
|00002b80| ff ff ff ff ff ff 00 01 | 00 00 00 00 00 00 00 02 |........|........|
|00002b90| 0b 98 04 88 0b cb 07 d4 | 00 00 00 00 00 14 00 0c |........|........|
|00002ba0| 00 00 00 00 00 01 00 01 | 00 01 00 2e 46 6f 6c 64 |........|....Fold|
|00002bb0| 20 74 6f 20 74 68 69 73 | 20 6c 69 6e 65 20 61 6e | to this| line an|
|00002bc0| 64 20 70 75 74 20 69 6e | 20 6d 61 69 6c 20 64 69 |d put in| mail di|
|00002bd0| 73 74 72 69 62 75 74 69 | 6f 6e 00 00 00 16 00 01 |stributi|on......|
|00002be0| 00 00 00 00 00 0c 00 09 | 00 14 00 00 00 0c 00 00 |........|........|
|00002bf0| 00 00 00 00 00 07 00 00 | 00 70 0b dc 03 4c 0c 24 |........|.p...L.$|
|00002c00| 06 c8 00 01 00 00 ff ff | ff ff ff ff ff ff 00 01 |........|........|
|00002c10| 00 00 00 00 00 00 00 02 | 0b dc 03 4c 0c 24 06 c8 |........|...L.$..|
|00002c20| 00 00 00 00 00 14 00 12 | 00 01 00 00 00 01 00 01 |........|........|
|00002c30| 00 01 00 1b 42 65 6e 65 | 66 69 74 73 20 2d 20 4d |....Bene|fits - M|
|00002c40| 61 69 6c 20 53 74 6f 70 | 20 2d 20 33 39 2d 46 98 |ail Stop| - 39-F.|
|00002c50| 00 00 00 16 00 01 00 00 | 00 00 00 13 00 0e 00 14 |........|........|
|00002c60| 01 00 00 12 00 00 00 00 | 00 00 00 07 00 00 00 c8 |........|........|
|00002c70| 02 6c 00 70 02 d3 09 20 | 00 01 00 00 ff ff ff ff |.l.p... |........|
|00002c80| ff ff ff ff 00 01 00 00 | 00 00 00 00 00 02 02 6c |........|.......l|
|00002c90| 00 70 02 d3 09 20 00 00 | 00 00 00 14 00 0c 00 00 |.p... ..|........|
|00002ca0| 00 00 00 01 00 01 00 02 | 00 74 54 68 69 73 20 66 |........|.tThis f|
|00002cb0| 6f 72 6d 20 6d 75 73 74 | 20 62 65 20 63 6f 6d 70 |orm must| be comp|
|00002cc0| 6c 65 74 65 64 20 61 6e | 64 20 74 75 72 6e 65 64 |leted an|d turned|
|00002cd0| 20 69 6e 20 74 6f 20 74 | 68 65 20 42 65 6e 65 66 | in to t|he Benef|
|00002ce0| 69 74 73 20 64 65 70 61 | 72 74 6d 65 6e 74 20 77 |its depa|rtment w|
|00002cf0| 69 74 68 69 6e 20 33 31 | 20 64 61 79 73 20 6f 66 |ithin 31| days of|
|00002d00| 20 74 68 65 20 65 66 66 | 65 63 74 69 76 65 20 64 | the eff|ective d|
|00002d10| 61 74 65 20 6f 66 20 63 | 68 61 6e 67 65 2e 00 00 |ate of c|hange...|
|00002d20| 00 16 00 01 00 00 00 00 | 00 0c 00 09 00 14 00 00 |........|........|
|00002d30| 00 0c 00 00 00 00 00 00 | 00 07 00 00 00 7c 0b 90 |........|.....|..|
|00002d40| 01 10 0b c7 04 3c 00 01 | 00 00 ff ff ff ff ff ff |.....<..|........|
|00002d50| ff ff 00 01 00 00 00 00 | 00 00 00 02 0b 90 01 10 |........|........|
|00002d60| 0b c7 04 3c 00 00 00 00 | 00 14 00 0c 00 00 00 00 |...<....|........|
|00002d70| 00 01 00 01 00 01 00 27 | 46 69 65 6c 64 20 53 69 |.......'|Field Si|
|00002d80| 74 65 73 3a 20 52 65 74 | 75 72 6e 20 74 6f 20 4c |tes: Ret|urn to L|
|00002d90| 6f 63 61 6c 20 48 52 20 | 4c 69 61 69 73 6f 6e ff |ocal HR |Liaison.|
|00002da0| 00 00 00 16 00 01 00 00 | 00 00 00 0c 00 09 00 14 |........|........|
|00002db0| 00 00 00 0c 00 00 00 00 | 00 00 00 00 00 00 00 03 |........|........|
|00002dc0| 00 00 00 34 00 10 00 10 | 0c 50 09 80 00 01 00 00 |...4....|.P......|
|00002dd0| 00 03 00 01 ff ff ff ff | ff ff ff ff 00 00 00 00 |........|........|
|00002de0| 00 00 00 00 00 00 00 01 | 00 28 00 28 00 28 00 28 |........|.(.(.(.(|
|00002df0| 00 00 00 00 00 00 00 00 | 00 07 00 00 00 a2 01 6c |........|.......l|
|00002e00| 00 10 01 d8 09 80 00 01 | 00 00 ff ff ff ff ff ff |........|........|
|00002e10| ff ff 00 01 00 00 00 00 | 00 00 00 02 01 6c 00 10 |........|.....l..|
|00002e20| 01 d8 09 80 00 00 00 00 | 00 15 00 0c 00 00 00 00 |........|........|
|00002e30| 00 03 00 03 00 01 00 4e | 50 4c 45 41 53 45 20 55 |.......N|PLEASE U|
|00002e40| 53 45 20 54 48 45 20 54 | 41 42 20 4b 45 59 20 54 |SE THE T|AB KEY T|
|00002e50| 4f 20 4d 4f 56 45 20 46 | 52 4f 4d 20 20 46 49 45 |O MOVE F|ROM  FIE|
|00002e60| 4c 44 20 54 4f 20 46 49 | 45 4c 44 20 57 48 45 4e |LD TO FI|ELD WHEN|
|00002e70| 20 46 49 4c 4c 49 4e 47 | 20 4f 55 54 20 54 48 49 | FILLING| OUT THI|
|00002e80| 53 20 46 4f 52 4d 00 00 | 00 16 00 01 00 00 00 00 |S FORM..|........|
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|00005a00| b6 db 00 00 00 00 00 04 | 40 00 40 00 00 00 01 00 |........|@.@.....|
|00005a10| 00 00 03 0c 00 00 02 0c | 00 00 00 7e 00 1a 89 7c |........|...~...||
|00005a20| 04 c8 00 00 00 1c 00 7e | 00 02 46 44 43 54 00 02 |.......~|..FDCT..|
|00005a30| 00 1a 54 55 54 20 00 01 | 00 3e 4e 58 54 4f 00 00 |..TUT ..|.>NXTO..|
|00005a40| 00 56 00 80 ff ff 00 00 | 00 00 00 00 00 00 00 81 |.V......|........|
|00005a50| ff ff 00 00 00 11 00 00 | 00 00 00 82 ff ff 00 00 |........|........|
|00005a60| 01 94 00 00 00 00 27 10 | ff ff 00 00 01 e4 00 1a |......'.|........|
|00005a70| 8a f2 27 11 ff ff 00 00 | 01 f4 00 1a 8b 12 27 10 |..'.....|......'.|
|00005a80| ff ff 00 00 02 04 00 1a | 8a 04 00 00 00 00 00 00 |........|........|
|00005a90| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00005aa0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00005ab0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00005ac0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00005ad0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00005ae0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
|00005af0| 00 00 00 00 00 00 00 00 | 00 00 00 00 00 00 00 00 |........|........|
+--------+-------------------------+-------------------------+--------+--------+