Summary of Revisions

SUMMARY OF REVISIONS TO CA-12

Page 1

Underneath Seal—deleted current expiration date and replaced with XX-XX-XXXX

Bottom of the Page, added Revision Date after Form #. CA-12 (11-10)

Page 2

Revised current forms to include Name/SSAN for B, C, and D)

As a result, the form has been revised and renumbered (B1, C4, D7, is noted as Name/SSAN)

Old Form New Form

B. 1, 2 1, 2, 3

C. 3, 4, 5 4, 5, 6

D. 6, 7, 8, 9 7, 8, 9, 10

E. 10, 11, 12 11, 12, 13

Sections B, C, and D. Old Form--Renumbered the If Yes as indicated 10, 11, 12,

New Form-- Renumbered as 13, 14, and 15.

Sections D and E Old Form—Additional Information… 1, 2, 3, 4, 5, 6, 7, or 9.

New Form—Renumbered as 2, 3, 5, 6, 7, 9, 10, or 12.

Section E. Old Form Space for Answers…10, 11, 12

New Form—Renumbered as 13, 14, and 15

Added Page # and Revision Date (Page 2 (11-10)