Contact Information

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Student Information Section
Recipient SSN:	XXX-XX-5654	Recipient Middle Initial:	A
Recipient DOD ID:	XXXXXX2345	Recipient Zip Code:	78701
Recipient Last Name:	Longi	Recipient Date of Birth:	1/1/1980
Recipient First Name:	Taimur

Benefit Usage Details Section
Hazlewood Hours Used:	11	Federal Hours Used:	0
Type of Hours Used:	Standard	Value of Exemption:	$4,750.00

Status Information Section
Relation to Service Member:	Self	Type of Hours Used:	Standard
Is Recipient a Dependent:	Y/N	Value of Exemption:	$4,750.00

Service Member Information section:
Service Member First Name:	A	Service Member Middle Name:	M
Service Member Last Name:	Longi