8a - Gift form

ATSS Gift Form

Incentive Information

CASEID {and barcode}

Are you the adult household member with the birthday that’s coming up next, and did you already complete the survey booklet?

If so, please choose one of the following:

$20 Walmart gift card

$20 Check

Please provide your name and telephone number:

- -

First Name Last Name Phone Number

Please review your address information and correct it if you see errors:

{FILL ADDRESS}

Address

{FILL CITY} {FILL STATE} {FILL ZIP CODE}

City State Zip Code

Please place your completed incentive information form in the small preaddressed envelope.

After RTI International has received your completed survey booklet, we will send your choice of gift card or check. You should receive it in an envelope with a blue RTI logo within 3–7 weeks.