SURVIVOR BENEFIT PROGRAM OFFSET IMPACT EXAMPLE

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MOAA

Attn: Col Lee Lange, USMC (Ret)

201 North Washington Street

Alexandria, VA 22314-2539

NAME:________________________________________________________________________________

STREET ADDRESS:___________________________________________________________________

CITY:_______________________________________ STATE:_________ ZIP CODE:______________

AGE:_________ YEAR YOU BECAME A WIDOW OR WIDOWER:_____________

SPOUSE'S SERVICE (ARMY, NAVY, ETC.):_______________________________________________

TELEPHONE (HOME)__________________________________________________________________

E-MAIL ADDRESS:____________________________________________________________________

DID YOU KNOW ABOUT THE SBP AGE 62 OFFSET/BENEFIT REDUCTION PROVISION AT AGE 62 WHEN YOUR SPOUSE ENROLLED IN THE SBP PROGRAM? YES______ NO______

WHAT WAS THE MONTHLY AMOUNT OF YOUR OFFSET AT AGE 62? (YOU DO NOT HAVE TO ANSWER THIS QUESTION IF YOU ARE NOT COMFORTABLE DOING SO): $_________________

IMPACT THAT THE SBP OFFSET BENEFIT/REDUCTION HAS HAD ON YOU (SUCH AS CHANGE IN LIFESTYLE, ETC.):

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(YOU MAY CONTINUE ON THE BACK OF THIS PAGE)

I AM WILLING TO TALK WITH A NEWSPAPER OR BROADCAST REPORTER ABOUT MY EXPERIENCES WITH THE SURVIVOR BENEFIT PROGRAM AND THE IMPACT ANY OFFSET HAS HAD ON MY LIFE: (PLEASE CHECK ONE)

YES________ N0__________

IF YOU ARE WILLING TO TALK WITH A MEMBER OF THE NEWS MEDIA, DO YOU WANT MOAA TO CALL YOU FIRST BEFORE GIVING YOUR NUMBER OUT TO REPORTER? (PLEASE CHECK ONE)

CALL ME FIRST_________ DON'T NEED TO CALL ME FIRST____________

SIGNATURE_________________________________________________

CONTINUATION OF IMPACT NARRATIVE (IF NEEDED): _________________________________

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