Paper Survey (including informed consent and screener)
New Applicant Survey (NAS)
Attachment A-1 NAS Questionnaire
Paper Survey (including informed consent and screener)
OMB:
Attachment A-1 NAS Survey Questionnaire
New Applicant Survey Questionnaire
Screener Section
S-1. This survey is intended for disability applicants. Are you the applicant or someone else?
Yes, I am the applicant [D-1]
No, I am filling out this survey on behalf of the applicant
S-2. What is the reason the applicant is not able to complete this survey? [SELECT ALL THAT APPLY]
A disability or physical/mental condition prevents them from completing the survey
They are currently incarcerated
They are deceased [S-5b]
They are living outside the U.S. or are on active duty in the military
Some other reason (SPECIFY)
S-3. Are you able to answer questions about this person’s application for disability benefits, including medical exams they may have taken for their application, challenges they may have filed, and the outcome of any decisions they may have received?
Yes [S-4]
No
Not sure
S-3.1. Is there someone else who can answer these questions?
No
Yes:
Write their name: __________________ and Phone: ____________________
[End Survey]
S-4. What is your relationship to the applicant?
Friend or family member
Lawyer or applicant representative
Service provider
Someone else. Tell us your relationship to the applicant:
Decision to Apply (D)
The Social Security Administration (SSA) wants to know about your experiences when you applied for disability benefits. These benefits include Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). Some people may apply for disability benefits from SSA more than once. For this survey, think only about your most recent application experience.
D-1. Did any of the people listed below influence your decision to apply for disability benefits? [CHECK ALL THAT APPLY]
A friend or family member
A doctor or health care professional
An employer or insurance company
Lawyer or caseworker
Someone else (SPECIFY):
None of the above
D-2. In the 12 months before you applied for benefits, were you experiencing any of the following? [CHECK ALL THAT APPLY]
You ate smaller meals or skipped meals because you didn’t have enough money for food
You were homeless or worried about becoming homeless
You had trouble paying for utilities (such as gas, electricity or phone)
You had trouble finding or paying for transportation
You had trouble finding or paying for care for a family member or child
You had trouble paying for medical care or medication
None of the above
D-3. In the 12 months before you applied for benefits, what types of assistance were you receiving? Include assistance from individuals, programs or organizations. [CHECK ALL THAT APPLY]
Food assistance
Housing assistance
Assistance with fuel, water or electricity
Transportation assistance
Childcare or adult caregiving assistance
Work training
Medical care assistance, free clinics or Medicaid
Cash assistance from government programs
Worker’s comp or private disability insurance
None of these
D-4. When you applied for benefits, for how long had you been unable to work due to a mental or physical health condition?
Less than a year
1-3 years
4-9 years
10+ years
I was working when I applied [D-6]
I was unable to work due to a reason other than a mental or physical health condition
Don’t know
D-5. Besides your health condition/s, what problems kept you from working in the 12 months before you applied for benefits? [CHECK ALL THAT APPLY]
You couldn’t find a job that would accommodate your health condition
You feared you would lose Medicaid or other benefits if you worked
You didn’t have transportation
A language barrier kept you from working
Some other problem NOT related to your physical or mental health condition/s (SPECIFY):_____
None of these
D-6. When you applied for benefits, were you experiencing serious financial problems?
Yes
No [D-7]
Don’t know [D-7]
D-6.1. How long had you been experiencing serious financial problems?
Less than a year
1-3 years
4-9 years
10+ years
Don’t know
D-7. Since the time you submitted your application, is your financial situation now better, worse, or the same?
Better [AE-1]
The same [AE-1]
Worse
Don’t’ know
D-8. Are you currently experiencing any of the following? [CHECK ALL THAT APPLY]
Eating smaller meals or skipped meals because you don’t have enough money for food
Homelessness or worried about becoming homeless
Trouble paying for utilities (such as gas, electricity or phone)
Trouble finding or paying or transportation
Trouble finding or paying for care for a family member or child
Trouble paying for medical care or medication
None of these
Application Experiences (AE)
This section of the survey asks you about your experiences applying for disability benefits.
AE-1. During the application or appeals process, did you visit one of SSA’s offices? Do not include any visits with health professionals you saw as part of your application.
Yes
No [AE-2]
Don’t know [AE-2]
AE-1.1. When you visited SSA’s offices...
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AE-1.2. What would have improved your office visit, if anything?
Please write in answer:
AE-2. Did a health condition make it hard for you to visit the office?
Yes
No [AE-3]
Don’t know [AE-3]
AE-2.1. What type of health condition made it hard for you to
visit the SSA office?
[CHECK ALL THAT APPLY]
A mental health condition (for example, depression or anxiety)
A learning disability or intellectual disability
A physical impairment
A hearing or visual impairment (for example, blindness or deafness)
Other (SPECIFY):
AE-3. During the application or appeals process, did you use SSA’s website?
Yes
No [AE-4]
Don’t know [AE-4]
AE-3.1. When you used SSA’s website…
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[If AE-3.1d = “Yes”]
AE-3.2. What problems did you have with the website? [CHECK ALL THAT APPLY]
Your application didn’t save and you had to start over
You were unable log into your account
You had trouble uploading documents
You could not find the information you were looking for
Some other problem (DESCRIBE IN THE BOX BELOW)
AE-3.3. How could SSA improve their website? Please describe in the box below:
AE-4. Did a health condition make it hard for you to use SSA’s website?
Yes
No [AE-5]
Don’t know [AE-5]
AE-4.1. What type of health condition made it hard for you to use
the website?
[CHECK ALL THAT APPLY]
A mental health condition (for example, depression or anxiety)
A learning disability or intellectual disability
A physical impairment
A hearing or visual impairment (such as, blindness or deafness)
Other (SPECIFY):
AE-5. During the application or appeals process, did you call SSA
or did SSA call you?
[CHECK ALL THAT APPLY]
Yes, I made a call to SSA
Yes, I received a call from SSA
No [AE-6]
Don’t know [AE-6]
AE-5.1. Tell us about your phone call experience. For the majority of calls…
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Don’t know |
Not applicable |
a. Did you talk to someone at SSA? |
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b. [If AE-5.1a = “yes”] Did you understand the information you received? |
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c. [If AE-5.1a = “yes”] Was the SSA staff you spoke with helpful? |
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d. If you missed a call from SSA, was it easy to call back or reschedule the appointment? |
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e. Did you wait on hold longer than you wanted to? |
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AE-5.2. How could SSA improve their phone support?
Please write in answer:
AE-6. Did a health condition make it hard for you to talk to someone over the phone?
Yes
No [AE-7]
Don’t know [AE-7]
AE-6.1. What type of health condition made it hard to talk to someone over the phone? [CHECK ALL THAT APPLY]
A mental health condition (for example, depression or anxiety)
A learning disability or intellectual disability
A physical impairment
A hearing or visual impairment (for example, blindness or deafness)
Other (SPECIFY):
AE-7. How hard or easy was it to complete your application? Include any efforts to get documentation for the application. Do not include any efforts to challenge a denial.
Very easy [AE-8]
Somewhat easy [AE-8]
Neither easy nor hard [AE-8]
Somewhat hard
Very hard
Don’t know [AE-8]
AE-7.1. Was it hard to complete the application because of your health condition?
Yes
No [AE-7.2]
Don’t know [AE-7.2]
AE-7.1.1. What type of condition made it hard to complete the application? [CHECK ALL THAT APPLY]
A mental health condition (for example, depression or anxiety)
A learning disability or intellectual disability
A physical impairment
A hearing or visual impairment (for example, blindness or deafness)
Some other condition (SPECIFY):
AE-7.2. Which sections of the application were hard to complete? [CHECK ALL THAT APPLY]
Medical conditions
Medications and medical treatments
Employment history
Income and expenses
Savings and assets
Entire application
[If any items selected in AE-7.2]
AE-7.2a. What was hard about those sections?
Please write in answer:
AE-8. Did the application provide enough opportunity for you to adequately document your condition/s?
Yes
No
Don’t know
AE-9. Did it take more time, less time or the same amount of time as you expected to complete your application? Include the time it took you to gather information or see doctors for evaluations.
More time
Less time
The same amount of time
Don’t know
AE-10. How could SSA improve the application?
Please write in answer:
AE-11. Did you have any of the following problems with SSA during the application or appeals process? [CHECK ALL THAT APPLY]
It was hard to get updates on the status of your application
SSA asked you to submit the same documents more than once
It was hard to meet SSA’s deadlines
A language barrier made it hard to communicate with SSA
You did not receive notices in a way that you could read or understand them (for example, you requested large font or Braille notices but did not receive them)
Other (SPECIFY):
None of the above
AE-12. During the application or appeals process, did SSA require you to visit a health professional for an evaluation?
No [R-1]
Don’t know [R-1]
Yes, but you haven’t had an evaluation yet [R-1]
Yes, you had an exam
AE-12.1. Did you have any of the following problems with the evaluation? [CHECK ALL THAT APPLY]
The evaluation was incomplete or not the right kind of evaluation for your condition
The health professional was not qualified to evaluate your condition
The location was not safe or accessible
A health condition made it hard for you to get to the evaluation
Other (SPECIFY):
None of these
[If AE-12.1 = “A Health condition made it hard for you to get an evaluation”]
AE-12.2. What type of health condition, if any, made it hard to
get to the evaluation?
[CHECK ALL THAT APPLY]
A mental health condition (for example, depression or anxiety)
A learning disability or intellectual disability
A physical impairment
A hearing or visual impairment (for example, blindness or deafness)
Some other condition (SPECIFY):
Representation (R)
This section of the survey asks you about receiving help with the most recent application you submitted, including help you received with your appeal.
R-1. Before you applied, did you know you could use a lawyer or official representative?
Yes
No
Don’t know
R-2. Who helped you with the application or appeals process? [CHECK ALL THAT APPLY]
A lawyer or official representative
A spouse, family member or friend
No one helped you
Don’t know [DA-1]
[If R-2 does not include “A lawyer or official representative”]
R-3. What is the main reason why you did not use a lawyer or official representative?
No one told you about using one
You asked a someone but they refused
You didn’t need help
You are waiting until later in the process to use one
You thought they cost too much
Some other reason (SPECIFY):
Don’t know
[After R-3 go to DA-1]
R-4. Where did you learn about using a lawyer or official representative? [CHECK ALL THAT APPLY]
A friend, family member, or coworker
A doctor or health care professional
A social service agency or social worker
A web search
An employer or insurance company
SSA’s materials or website
From TV, radio, a billboard, some other advertisement, or social media
From somewhere else (SPECIFY):
You already knew about it
Don’t know
R-5. When did you begin working with a lawyer or official representative?
Before you started the application
While you were submitting your application
After SSA denied your application or during the appeals process
Some other time
Don’t know
R-6. Why did you use a lawyer or official representative? [CHECK ALL THAT APPLY]
Someone advised you to get one
You wanted help completing the application
You wanted help with an appeal or court hearing
You wanted help because of a language barrier
You wanted help because of a learning disability or intellectual disability
Some other reason (SPECIFY):
Don’t know
R-7. How did your lawyer or official representative ask to be paid?
A percentage of your awarded backpay
A flat fee
They collect the payment from someone else (for example, an insurance company or government agency)
They do not receive any pay
Some other way (SPECIFY):
Don’t know
R-8. What did your lawyer or official representative help you with? [CHECK ALL THAT APPLY]
Filling out the application
Requesting information from doctors or employers
Filing an appeal or reconsideration
Attending court hearings
Communicating with SSA about the status of your application
Something else (SPECIFY):
They did not help with anything
R-9. How satisfied are you with your lawyer or official representative?
Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied
Don’t know
[If R-9 = “Somewhat dissatisfied” or “Very dissatisfied”]
R-9.1. What made you feel dissatisfied with your lawyer or
official representative?
[CHECK ALL THAT APPLY]
Getting a decision took longer because they caused delays
They did not regularly communicate with you about your case
They did not help you with your application or appeal as much as you expected
Some other problem (SPECIFY):
Don’t know
Denials and Appeals (DA)
This section will ask you about what happened after you submitted your application for disability benefits.
DA-1. After submitting your most recent application, did you receive any denials? Check “Yes” even if you appealed the last decision.
Yes [DA-2]
No
Don’t know
DA-1.1. Have you waited longer than you expected for a decision?
Yes
No
Don’t know
[After DA-1.1 go to DA-8]
DA-2. When you were denied, did SSA give you enough information to understand why you did not qualify for benefits?
Yes
No
Don’t know
DA-3. After you were denied, did you challenge the decision? Challenges may include reconsiderations or appeals.
Yes [DA-5]
No
Don’t know
DA-4. What were the reasons you did not challenge the decision? [CHECK ALL THAT APPLY]
You felt you were unlikely to be successful
You did not understand how
You needed help from a lawyer or someone else, but could not get it
You missed the deadline
You were too tired or discouraged to continue
You are still deciding
Some other reason (SPECIFY):
Don’t know
[After DA-4, Go to EP-1]
DA-5. Did anyone give you information
about how to challenge the decision you received?
[CHECK ALL
THAT APPLY]
Yes, you received information from SSA
Yes, you received information or help from a lawyer or official representative
Yes, you received information or help from someone else (SPECIFY):
No, you did not receive information or help
Don’t know
[If DA-5 = “Yes, you received information from SSA”]
DA-5.1. How helpful was SSA’s information about how to challenge the decision?
Very helpful
Somewhat helpful
Neither helpful nor unhelpful
Not helpful at all
Don’t know
[If DA-5.1 = “Not helpful at all”]
DA-5.2. What made the information you received from SSA unhelpful? [CHECK ALL THAT APPLY]
You didn’t understand it
You were not given enough information
The information you received was not accurate
It was unhelpful for some other reason (SPECIFY):
Don’t know
DA-6. There are several ways to challenge a denial. Which of these
have you requested?
[CHECK ALL THAT APPLY]
A reconsideration
A hearing with an Administrative Law Judge
An Appeals Council Review
A Federal Court hearing
Don’t know
DA-7. Once you filed the paperwork to challenge the denial, how long did you expect to wait for a final decision?
Less than 3 months
4-6 months
6-12 months
More than a year
I had no expectations
Don’t know
DA-8. Are you currently receiving disability benefits?
Yes
No [DS-1]
Don’t know
Early Program Experiences (EP)
This section asks you about your experiences after SSA approved the most recent application you submitted.
EP-1. Was the amount of backpay (retroactive payments) you received as much as you expected?
It was more than you expected
It was about what you expected
It was less than you expected
You had no expectations about the amount
Don’t know
EP-2. When you applied, did you know how much the monthly payment would be?
Yes
No [EP-3]
Don’t know [EP-3]
EP-2.1. Is your monthly payment as much as you expected?
Yes
No
Don’t know
EP-3. Have disability benefits helped you meet your financial needs?
Yes, a little
Yes, a lot
No, not at all
Don’t know yet
EP-4. People receiving disability benefits must comply with certain program requirements. Do you understand the requirements for reporting changes to your….
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EP-5. How easy or hard do you think it will be to keep up with SSA’s program requirements to continue receiving your disability payments and benefits?
Very easy
Somewhat easy
Neither easy nor hard
Somewhat hard
Very hard
Don’t know
EP-6. How easy or hard has it been to communicate with SSA about your disability payments and benefits when you have needed to?
Very easy
Somewhat easy
Neither easy nor hard
Somewhat hard
Very hard
Don’t know
You don’t communicate with SSA
[If EP-6 = “Somewhat hard” or “Very hard”]
EP-6.1. What difficulties have you had communicating with SSA about your disability payments or benefits? [CHECK ALL THAT APPLY]
You have had difficulties using the SSA website
You have had difficulties reaching SSA by phone
Mail to/from SSA has been delayed or lost
You have had difficulties understanding information you received from SSA
Information you received from SSA has not been accurate
You have had other difficulties
communicating with SSA about your benefits.
(SPECIFY):
None of these
Don’t know
EP-7. Special rules make it possible for people with disability benefits to work and still receive monthly payments. Do you plan to work at all while you are receiving disability benefits?
Yes
Maybe
No [DS-1]
Don’t know [DS-1]
EP-8. Do you see yourself working and earning enough to stop receiving disability payments and benefits in the future?
Yes
No
Don’t know
Discrimination (DS)
DS-1. Now, think about your experiences with the most recent application you submitted. Did you have any interactions with people who work for SSA, lawyers, doctors, and judges during the application or appeals process?
Yes
No [SS-1]
Don’t know [SS-1]
The following questions are about experiences related to who you are. This includes both how you describe yourself and how others might describe you, for example, your skin color, ancestry, nationality, religion, gender, sexuality, age, weight, or disability.
DS-1a. Now, think about your experiences with the most recent application you submitted. This includes all interactions with people who work for SSA, lawyers, doctors, and judges. During the application or appeals process, because of who you are, have you . . .
[CHECK ONE BOX PER ROW]
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[If any items marked “Yes” continue, else go to SS-1]
DS-2. Why do you think you were treated in those ways during the
application process?
[CHECK ALL THAT APPLY]
Sex
Ancestry or national origins
Race
Age
Religion
Disability
Weight
Some other aspect of your physical appearance
Gender identity
Sexual orientation
Education or income level
Something else (SPECIFY):
Don’t know
DS-3. Who treated you in those ways during the application process? [CHECK ALL THAT APPLY]
SSA staff you saw in-person
SSA staff you talked to on the phone
Health professionals who evaluated your condition
Your lawyer or official representative
Administrative Law Judges
Someone else (SEPCIFY):
Don’t know
Social and Application Support (SS)
The next questions ask about support you received with the most recent application you submitted.
SS-1. What kinds of support did your family, friends, or other people provide to help with your application? Do not include any help you received from a lawyer or official representative. [CHECK ALL THAT APPLY]
Help filling out or understanding the application
Help gathering materials for your application, such as personal documents or medical records
Help with contacting SSA or sending documents to SSA
Help finding or using a lawyer or official representative
Transportation to SSA’s office or a doctor’s office for an exam requested by SSA
Other types of help or support (SPECIFY):
You did not receive support from family, friends, or other people in your community [DM-1]
SS-2. Who provided you with support or help with the most recent application you submitted? [CHECK ALL THAT APPLY]
Your spouse or significant other
Family members (children, parents or other family)
Friends or neighbors
A social worker or case worker
Someone else (SPECIFY):
SS-3. In general, how often do you get the support you need from family, friends and other people in the community?
Always
Usually
Sometimes
Rarely
Never
Don’t know
Demographics (DM)
The next questions ask you to provide some background information about yourself.
DM-1. What is your marital status?
Married
Separated
Divorced
Widowed
Never married
DM-2. What is the highest grade or year of school you have completed?
Never attended school or only attended kindergarten
Grades 1 through 6
Grades 7 through 11
Grade 12 or GED
College, 1 year to 3 years
College, 4 years or more
Don’t know
DM-3. What is your current gender? [CHECK ALL THAT APPLY]
Man
Woman
Nonbinary, genderqueer, gender-nonconforming, or agender
Another gender (SPECIFY)
Decline to answer
DM-4. What sex were you assigned at birth, meaning on your original birth certificate?
Male
Female
Decline to answer
DM-5. Which of the following best represents how you think of yourself?
Straight
Gay
Bisexual
Something else (SPECIFY):
Don’t know
DM-6. What is your race and/or ethnicity? Check all that apply and enter additional details in the spaces below. You may select more than one group. [CHECK ALL THAT APPLY]
American Indian or Alaskan Native
[If American Indian or Alaskan Native is selected] If desired, provide additional details below
Specify________________ (Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya etc.)
Asian
[If Asian is selected] If desired, provide additional details below
Chinese Asian Indian Filipino Vietnamese Korean Japanese
Other________________ (Enter, for example, Pakistani, Hmong, Afghan etc.)
Black or African-American
[If Black or African-American is selected] If desired, provide additional details below
African American Jamaican Haitian Nigerian Ethiopian Somali
Other________________ (Enter, for example, Trinidadian and Tobagian, Ghanaian, Congolese, etc.)
Hispanic or Latino
[If Hispanic or Latino is selected] If desired, provide additional details below
Mexican Puerto
Rican Salvadoran
Cuban
Dominican
Guatemalan
Other________________
(Enter, for example, Colombian, Spaniard, Honduran, etc.)
Middle Eastern or North African
[If Middle Eastern or North African is selected] If desired, provide additional details below
Lebanese Iranian Egyptian Syrian Iraqi Israeli
Other________________ (Enter, for example, Moroccan, Yemeni, Kurdish, etc.)
Native Hawaiian or Pacific Islander
[If Native Hawaiian or Pacific Islander is selected] If desired, provide additional details below
Native Hawaiian Samoan Chamorro Tongan Fijian Marshallese
Other________________ (Enter, for example, Palauan, Tahitian, Chuukese, etc.)
White
[If White is selected] If desired, provide additional details below
English German Irish Italian Polish Scottish
Other________________ (Enter, for example, French, Swedish, Norwegian, etc.)
DM-7. What languages do you usually speak? [CHECK ALL THAT APPLY]
English
Spanish
Some other language (SPECIFY):
DM-8. Overall, how confident do you feel using computers, smartphones, or other electronic devices to do the things you need to do online?
Very confident
Somewhat confident
Not at all confident
Don’t know
DM-9. If you wanted to use SSA’s website, where would you be able to access it? [CHECK ALL THAT APPLY]
At your home
At someone else’s home
At work
In public spaces (for example, the library or businesses with free Wi-Fi)
Some other place (SPECIFY):
None of these
DM-10. Which of these devices do you own? [CHECK ALL THAT APPLY]
Desktop or laptop computer
Printer
iPad or other tablet
Smartphone (such as iPhone, Android, or Blackberry)
Regular cell phone (not a smartphone)
None of the above
DM-11. From which of the following sources do you typically get information? [CHECK ALL THAT APPLY]
National news organizations (newspapers, TV, radio shows, podcasts, etc.)
Social media such as TikTok, Facebook, X (formerly known as Twitter), or Instagram
Family and friends
Local public library or librarian
Local news organizations
Government agencies (websites, mail, phone, or in-person)
Professionals like health care providers or lawyers
Somewhere else: (SPECIFY) __________
DM-12. How much do you trust the following information sources when it comes to making decisions? [CHECK ONE PER ROW].
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Some |
Not too much |
Not at all |
Not sure |
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DM-13. Have you ever served on active duty in the U.S. Armed Forces, the Reserves, or in the National Guard?
Yes
No
DM-14. Who have you been living with during the past 30 days? Include children who live with you part-time because of joint custody, but not other part-time residents. [CHECK ALL THAT APPLY]
I live by myself
Spouse or significant other
Children (including any adult children)
Grandchildren
Parents
Other relatives (other than spouse or significant other, children, grandchildren, or parents)
Friends
Other non-related adults (roommates)
Other (SPECIFY):
Income, Benefits, and Services (IB)
The next questions ask you for some information about your income and any benefits or services you may receive. You answers will not affect your disability application or benefits.
IB-1. In 2024, what was your total household income before taxes? Please include money that all members of your household received from all sources. [CHECK ONLY ONE ANSWER]
Less than $25,000
$25,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $149,999
$150,000 to $199,999
$200,000 or more
Don’t know / Not sure
IB-2. Are you currently receiving income from any of the following sources? [CHECK ONE PER ROW]
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IB-3. Which of the following best describes your current work status? [SELECT ALL THAT APPLY]
Unable to work
Have a job but currently not at work (for instance, on a leave of absence or suspended)
Working full or part time.
(TELL US
HOW MANY HOURS PER WEEK DO YOU TYPICALLY WORK):
Looking for work
Keeping house or caregiving
Doing volunteer work
Going to school or doing vocational training
Retired
Other (SPECIFY):
IB-4. What types of health insurance or health coverage plans you currently have? [CHECK ALL THAT APPLY]
Medicaid (or other public insurance for those with low incomes or a disability)
Medicare (for people 65 and older or certain people with disabilities)
Insurance through an employer or privately insured
VA (including those who have ever used or enrolled for VA health care)
TRICARE, TRICARE for life, or other military health care
Indian Health Service or other native health plans
You don’t have health insurance
Other (SPECIFY):
Don’t know
This is the end of the survey. Click ‘Submit’ to submit your answers
Post-Survey
PS-1. Please select how you/ [IF S1 = No [NAME]] would like to receive the $40 for completing the New Applicant Survey. You should receive it in the next 10 – 14 days. Answer is required
Check
Pre-paid gift card
PS-2. Please confirm the address we have for you/ [IF S1 = No [NAME]] is correct
[Display address]
This address is correct [End]
This address is incorrect
PS-2a. Please provide the correct mailing address where we can mail the pre-paid gift card or check.
Street 1: ______________________
Street 2: ______________________
City: ______________________ State: ______________________ Zip: _______
Final Screen
Thank you! You may close your browser.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Lori Houck |
| File Modified | 0000-00-00 |
| File Created | 2024-11-10 |
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