unstructuredio/SCORE-Bench · Datasets at Hugging Face

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9. Dependent's address (Include ZIP Code)
2010 Quincy St Arlington VA 22203
10. Dependent's birth date (Mo., day, year)
Mar. 2, 1960
11. Dependent's Occupation
N/A
12. Dependent's Social Security Number
486-27-5234
13. Dependent's relationship to employee
mother
14. Extent of dependency on employee
[] Total [x] Partial
15.Total amount employee contributed to dependent's support during 12 months immediately prior to death.
$ 68,000
16. Did employee live with dependent during the 12 months immediately prior to death?
[] Yes [x] No
If "Yes", Complete 17 & 18.
17. Total amount employee paid dependent in money or service for room and board in addition to amount shown in 15.
$ ___ Per ___
18. If no fixed amount was paid for room and board, what is the fair value of such room and board?
$ ___ Per ___
19. If dependent was employed during 12 month period prior to employee's death, give:
Type of work performed: ___
Period of employment: ___ ___
Monthly pay rate: ___
Name and address of employer: ___
20. Show dependent's income from all sources other than employment during 12 month period prior to employee's death:
Investments $ ___
Pensions 12,000
Persons other than employee 3,700
Other ___
Total $ ___
Information about spouse (Items 21 through 25)
21. Birth Date (Mo., day, year) ___
22. Occupation ___
23. Monthly pay rate
$ ___
24. Total income from all sources for 12 months prior to employee's death. $ ___

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25. List all property owned by dependent and spouse (omit clothing, furniture, personal items).
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Description Date Acquired Value
2016 Mercedes E320 Sedan unknown $9,500
Home at address given in 9 11/23/2020 $663,000
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26. If an application has been made for U.S. Civil Service Annuity or any other Federal Retirement or Disability Law because of employee's death, give:
Retirement System: [] CSRS [] FERS [x] SSA [] Other
Claim number for each claim: a. 78250048
b. ___
Date each benefit began: a. not yet
b. ___
Amount of each benefit paid per month: $ a. unknown
b. ___
27. If an application has been made for Veterans Administration (VA) benefits because of employee's death, give:
Service number: ___
VA Claim number: ___
Address of VA office where claim is filed: ___ ___ ___ ___ ___

28. If a claim has been made against a third party because of employee's death, give:
Amount of recovery: $ ___
Name and address of third party:
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___

29. Total burial expense
$ 8,000.00
30. Amount of burial expense paid or payable by VA
$ 0
31. Name and address of party (other than VA) whose funds were used to pay burial expense and amount paid:

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Adarsh Reddy Rm 310 Bethesda Hospital
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___
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MD 20914
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$

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6,500
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32. Name of Financial Institution for Depositing Benefits: Capital Bank [] Checking [x] Savings
33. Account number: 22222268-14
34. Routing or transit number:

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121137726
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I certify that the information provided above is true and accurate to the best of my knowledge and belief. Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud, to obtain compensation as provided by the FECA, or who knowingly accepts compensation to which that person is not entitled is subject to civil or administrative remedies as well as criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment, or both. In addition, a state or federal criminal conviction for FECA fraud will result in termination of all current and future FECA benefits.
35. Signature of person filing claim

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9. Dependent's address (Include ZIP Code)

2010 Quincy St Arlington VA 22203

10. Dependent's birth date (Mo., day, year)

Mar. 2, 1960

11. Dependent's Occupation

N/A

12. Dependent's Social Security Number

486-27-5234

13. Dependent's relationship to employee

mother

14. Extent of dependency on employee

[] Total [x] Partial

15.Total amount employee contributed to dependent's support during 12 months immediately prior to death.

$ 68,000

16. Did employee live with dependent during the 12 months immediately prior to death?

[] Yes [x] No

If "Yes", Complete 17 & 18.

17. Total amount employee paid dependent in money or service for room and board in addition to amount shown in 15.

$ ___ Per ___

18. If no fixed amount was paid for room and board, what is the fair value of such room and board?

$ ___ Per ___

19. If dependent was employed during 12 month period prior to employee's death, give:

Type of work performed: ___

Period of employment: ___ ___

Monthly pay rate: ___

Name and address of employer: ___

20. Show dependent's income from all sources other than employment during 12 month period prior to employee's death:

Investments $ ___

Pensions 12,000

Persons other than employee 3,700

Other ___

Total $ ___

Information about spouse (Items 21 through 25)

21. Birth Date (Mo., day, year) ___

22. Occupation ___

23. Monthly pay rate

$ ___

24. Total income from all sources for 12 months prior to employee's death. $ ___

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25. List all property owned by dependent and spouse (omit clothing, furniture, personal items).

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Description Date Acquired Value

2016 Mercedes E320 Sedan unknown $9,500

Home at address given in 9 11/23/2020 $663,000

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26. If an application has been made for U.S. Civil Service Annuity or any other Federal Retirement or Disability Law because of employee's death, give:

Retirement System: [] CSRS [] FERS [x] SSA [] Other

Claim number for each claim: a. 78250048

b. ___

Date each benefit began: a. not yet

b. ___

Amount of each benefit paid per month: $ a. unknown

b. ___

27. If an application has been made for Veterans Administration (VA) benefits because of employee's death, give:

Service number: ___

VA Claim number: ___

Address of VA office where claim is filed: ___ ___ ___ ___ ___

28. If a claim has been made against a third party because of employee's death, give:

Amount of recovery: $ ___

Name and address of third party:

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___

29. Total burial expense

$ 8,000.00

30. Amount of burial expense paid or payable by VA

$ 0

31. Name and address of party (other than VA) whose funds were used to pay burial expense and amount paid: