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A. NAME OF PERSON(S) OR ORGANIZATION B. ADDRESS OF PERSON(S) OR ORGANIZATION
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Brown & White Law Firm 789 W 42nd St, Charlottesville, VA
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10. SPECIFY THE SECURITY QUESTION YOU WANT USED WHEN VERIFYING THE IDENTITY OF YOUR DESIGNATED THIRD PARTY. CHECK ONLY ONE SECURITY QUESTION BOX IN 10A AND PROVIDE THE ANSWER IN 10B. (Veteran/annuitant should answer the question and inform third-party of the answer.)
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A. SECURITY QUESTION B. ANSWER
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[] The city and state your mother was born in ___
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[] The name of the high school you attended ___
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[x] Your first pet's name Fluffy
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[] Your favorite teacher's name ___
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[] Your father's middle name ___
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11A. SIGNATURE (Sign in ink)
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11B. DATE SIGNED
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10-28-25
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PRIVACY ACT INFORMATION: No insurance may be converted unless a completed application form has been received (38 U.S.C. 1904 and 1942). The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 5, Code of Federal Regulations 1.526 for routine uses as identified in VA system of records, 36VA29, Veterans and Uniformed Services Personnel Programs of U.S. Government Life Insurance - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. The responses you submit are considered confidential (38 USC 5701).
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RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control Number. The OMB control number for this project is 2900-0856, and it expires 04/30/2027. Public reporting burden for this collection of information is estimated to average 5 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden to VA Reports Clearance Officer at vapra@va.gov. Please refer to OMB Control No. 2900-0856 in any correspondence. Do not send your completed VA Form 29-0975 to this email address.
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VA FORM
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APR 2024
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29-0975
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Page 2
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--------------------------------------------------- Unstructured Plain Text Format 1.0.4
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+12V 1
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U2 +12V 9 D1 2 1
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GND 7 5 3
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C1 2 1 10uF
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C2 2 1 10uF
|
1 GND
|
–12V 1 D4 1 2
|
D3 2 1
|
–12V 1
|
1 GND
|
+12V 1
|
C4 2 1 100nF
|
U1 V+ 8 V– 4
|
1 GND
|
C6 2 1 100nF
|
–12V 1
|
+12V 1
|
U3 V+ 4
|
V– 11
|
C3 2 1 100nF
|
1 GND
|
C5 2 1 100nF
|
–12V 1
|
U3.4
|
2 –A 1
|
3 +
|
1 GND
|
+12V 1
|
2k 2 1 R1
|
U1.1
|
2 –A 3 + 1
|
+5V 1
|
REF+5
|
100k 1 2
|
100k 1 2
|
–5V 1
|
U1.2
|
6 – B 5 + 7
|
1 GND
|
10k 2 1 R4
|
2 1 3 D2 CJ431
|
10k 2 1 R5
|
1 GND
|
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