Question 6 – 7: First Name, Last Name

Report the recipient’s complete legal first name in question 1 and complete legal last name in question 2.

Question 8: Indicate language preference:

Select the recipient’s primary language preference. If the recipient’s language is not listed as an option, value select ‘other’ and proceed to question 9.

Question 9: Specify other language preference:

Indicate the recipient’s language preference in the open text field provided.

Question 10: Does this contact have a U.S. mailing address?

Indicate if the recipient has a street address located in the U.S. (only inclusive of the 50 states and Washington D.C.). If the recipient resides in a U.S. territory including: Puerto Rico, Northern Mariana Island, United States Virgin Islands, American Samoa, or the United States minor outlying islands, then answer ‘no’ and complete the form using the international address question format in question 12.

Question 11: Street, City, State, Zip Code:

Indicate the recipient’s current U.S. home address.

Question 12: Country, International address:

Indicate the recipient’s current U.S. territory or international home address.

Question 13: Specify time zone (of mailing address)

Indicate the time zone of the recipient’s mailing address based on Universal Coordinated Time (UTC). If the recipient has a U.S. mailing address within the Samoa or Chamorro time zone or has an international mailing address, then select ‘other’ and report time zone in question 14.

Question 14: Specify other time zone:

Only answer this question if the time zone for the recipient’s mailing address was not listed above. Indicate time zone in the open text field.

Questions 15 – 18: Phone number(s) – Home / Work / Cell / Other:

For questions 15 – 18, provide phone numbers at which the recipient can be contacted for each type of phone number available. A phone number does not need to be provided for each phone number type however; at least one phone number is required.

Indicate area code when reporting U.S. phone numbers. Indicate country code for all international phone numbers.

Question 19: Specify other phone number type:

If the recipient’s preferred phone number type is not a home / work / or cell phone number, indicate the other phone number type here. Examples may include: spouse / significant other’s phone number, nursing home phone number, etc.

Questions 20 – 21: E-mail address(es) – primary / secondary

Indicate the recipient’s primary and secondary e-mail address (if applicable). When using the open text field be sure to provide a complete e-mail address including: user e-mail prefix, “@” symbol, and e-mail domain (ex: JohnDoe@comcast.net, JaneDoe@gmail.com).

Section Updates:

Question Number Date of Change Add/Remove/Modify Description Reasoning (If applicable)
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Last modified: Dec 22, 2020

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