unstructuredio/SCORE-Bench · Datasets at Hugging Face

text stringlengths 0 2.18k
33. TYPE OF ACCOUNT
[] CHECKING [] SAVINGS
34. BANK ROUTING NUMBER (NINE DIGIT FIELD) ___
35. BANK ACCOUNT NUMBER ___

--------------------------------------------------- Unstructured Image Begin
The bank routing number is always 9 digits and appears between the \|: symbols.
↳
--------------------------------------------------- Unstructured Check Begin
Beneficiary Name
Street Address
City, State, ZIP
--------------------------------------------------- Unstructured Caption Begin
SAMPLE CHECK
--------------------------------------------------- Unstructured Caption End
Check No. 1234
PAY TO THE ORDER OF ___ $ ___ ___
Dollars
\|:123456789\|: 1617284958569678\|\|: 1234
--------------------------------------------------- Unstructured Check End

Bank Routing Number Bank Account Number Check Number (Not needed)
↙︎
The bank account number varies in length and may contain dashes or spaces. The \|\|: symbol indicates the end of the account number.
--------------------------------------------------- Unstructured Image End

NOTE: DO NOT USE A DEPOSIT SLIP TO LOCATE YOUR BANKING INFORMATION. THIS INFORMATION CAN BE DIFFERENT THAN YOUR ACCOUNT INFORMATION AND COULD RESULT IN DELAYING PAYMENT.

--------------------------------------------------- Unstructured Sub-Title Begin
SECTION VII: SIGNATURE AND CERTIFICATION
--------------------------------------------------- Unstructured Sub-Title End
(All information requested in this section is required)

IMPORTANT: This form must be signed by the beneficiary, guardian, attorney-in-fact, or fiduciary, in Item 36, for payment to be made for an individual beneficiary. Otherwise, the trustee (for trusts), executor/administrator (for estates), or authorized representative (for an organization, charity, or legal entity) must sign in Item 36, for payment to be made.

CERTIFICATION: I certify that the above entries are true and correct to the best of my knowledge and belief.
36. SIGNATURE OF BENEFICIARY (Guardian, Attorney-In-Fact, or Fiduciary), OR TRUSTEE, EXECUTOR, OR REPRESENTATIVE ___

37. DATE SIGNED (MM/DD/YYYY) ___

NOTE: An "X" for signature is acceptable if the beneficiary cannot sign his/her name but is competent to handle his/her own affairs, and "X" for a signature is acceptable when witnessed by two impartial people. Impartial person is one not having a vested interest.

38A. PRINTED NAME OF FIRST WITNESS ___
38B. MAILING ADDRESS OF FIRST WITNESS ___
38C. TELEPHONE NUMBER OF FIRST WITNESS (Include Area Code) ___
38D. SIGNATURE OF FIRST WITNESS ___
38E. DATE SIGNED (MM/DD/YYYY) ___
39A. PRINTED NAME OF SECOND WITNESS ___
39B. MAILING ADDRESS OF SECOND WITNESS ___
39C. TELEPHONE NUMBER OF SECOND WITNESS (Include Area Code) ___
39D. SIGNATURE OF SECOND WITNESS ___
39E. DATE SIGNED (MM/DD/YYYY) ___

YOU CAN SUBMIT THE COMPLETED FORM BY DOCUMENT UPLOAD OR MAILING TO THE ADDRESS BELOW.

DOCUMENT UPLOAD:
Upload the form using our secure website at: https://insurance.va.gov/home/IDU

MAIL TO:
Department of Veterans Affairs Insurance Center
PO Box 5209 Janesville, WI 53547-5209

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).
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 2900-0060, and it expires 12/31/2027. Public reporting burden for this collection of information is estimated to average 6 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 [email protected]. Please refer to OMB Control No. 2900-0060 in any correspondence. Do not send your completed VA Form 29-4125 to this email address.
--------------------------------------------------- Unstructured Form End

--------------------------------------------------- Unstructured Page Footer Begin
VA FORM 29-4125, DEC 2024
--------------------------------------------------- Unstructured Page Number Block Begin
PAGE 3
--------------------------------------------------- Unstructured Page Number Block End
--------------------------------------------------- Unstructured Page Footer End
--------------------------------------------------- Unstructured Plain Text Format 1


--------------------------------------------------- Unstructured Image Begin
NVSS
--------------------------------------------------- Unstructured Image End


--------------------------------------------------- Unstructured Title Begin
Vital Statistics Rapid Release
--------------------------------------------------- Unstructured Title End
Report No.23 August 2022



--------------------------------------------------- Unstructured Title Begin
Provisional Life Expectancy Estimates for 2021
--------------------------------------------------- Unstructured Title End



Elizabeth Arias, Ph.D., Betzaida Tejada-Vera, M.S., Kenneth D. Kochanek, M.A., and Farida B. Ahmad, M.P.H.



--------------------------------------------------- Unstructured Sub-Title Begin
Introduction
--------------------------------------------------- Unstructured Sub-Title End

33. TYPE OF ACCOUNT

[] CHECKING [] SAVINGS

34. BANK ROUTING NUMBER (NINE DIGIT FIELD) ___

35. BANK ACCOUNT NUMBER ___

--------------------------------------------------- Unstructured Image Begin

The bank routing number is always 9 digits and appears between the |: symbols.

↳

--------------------------------------------------- Unstructured Check Begin

Beneficiary Name

Street Address

City, State, ZIP

--------------------------------------------------- Unstructured Caption Begin

SAMPLE CHECK

--------------------------------------------------- Unstructured Caption End

Check No. 1234

PAY TO THE ORDER OF ___ $ ___ ___

Dollars

|:123456789|: 1617284958569678||: 1234

--------------------------------------------------- Unstructured Check End

Bank Routing Number Bank Account Number Check Number (Not needed)

↙︎

The bank account number varies in length and may contain dashes or spaces. The ||: symbol indicates the end of the account number.

--------------------------------------------------- Unstructured Image End

NOTE: DO NOT USE A DEPOSIT SLIP TO LOCATE YOUR BANKING INFORMATION. THIS INFORMATION CAN BE DIFFERENT THAN YOUR ACCOUNT INFORMATION AND COULD RESULT IN DELAYING PAYMENT.

--------------------------------------------------- Unstructured Sub-Title Begin

SECTION VII: SIGNATURE AND CERTIFICATION

--------------------------------------------------- Unstructured Sub-Title End

(All information requested in this section is required)

IMPORTANT: This form must be signed by the beneficiary, guardian, attorney-in-fact, or fiduciary, in Item 36, for payment to be made for an individual beneficiary. Otherwise, the trustee (for trusts), executor/administrator (for estates), or authorized representative (for an organization, charity, or legal entity) must sign in Item 36, for payment to be made.

CERTIFICATION: I certify that the above entries are true and correct to the best of my knowledge and belief.

36. SIGNATURE OF BENEFICIARY (Guardian, Attorney-In-Fact, or Fiduciary), OR TRUSTEE, EXECUTOR, OR REPRESENTATIVE ___

37. DATE SIGNED (MM/DD/YYYY) ___

NOTE: An "X" for signature is acceptable if the beneficiary cannot sign his/her name but is competent to handle his/her own affairs, and "X" for a signature is acceptable when witnessed by two impartial people. Impartial person is one not having a vested interest.

38A. PRINTED NAME OF FIRST WITNESS ___

38B. MAILING ADDRESS OF FIRST WITNESS ___

38C. TELEPHONE NUMBER OF FIRST WITNESS (Include Area Code) ___

38D. SIGNATURE OF FIRST WITNESS ___

38E. DATE SIGNED (MM/DD/YYYY) ___

39A. PRINTED NAME OF SECOND WITNESS ___

39B. MAILING ADDRESS OF SECOND WITNESS ___

39C. TELEPHONE NUMBER OF SECOND WITNESS (Include Area Code) ___

39D. SIGNATURE OF SECOND WITNESS ___

39E. DATE SIGNED (MM/DD/YYYY) ___

YOU CAN SUBMIT THE COMPLETED FORM BY DOCUMENT UPLOAD OR MAILING TO THE ADDRESS BELOW.

DOCUMENT UPLOAD:

Upload the form using our secure website at: https://insurance.va.gov/home/IDU

MAIL TO:

Department of Veterans Affairs Insurance Center

PO Box 5209 Janesville, WI 53547-5209

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).

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 2900-0060, and it expires 12/31/2027. Public reporting burden for this collection of information is estimated to average 6 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 [email protected]. Please refer to OMB Control No. 2900-0060 in any correspondence. Do not send your completed VA Form 29-4125 to this email address.

--------------------------------------------------- Unstructured Form End

--------------------------------------------------- Unstructured Page Footer Begin

VA FORM 29-4125, DEC 2024

--------------------------------------------------- Unstructured Page Number Block Begin

PAGE 3

--------------------------------------------------- Unstructured Page Number Block End

--------------------------------------------------- Unstructured Page Footer End

--------------------------------------------------- Unstructured Plain Text Format 1

--------------------------------------------------- Unstructured Image Begin

NVSS

--------------------------------------------------- Unstructured Image End

--------------------------------------------------- Unstructured Title Begin

Vital Statistics Rapid Release

--------------------------------------------------- Unstructured Title End

Report No.23 August 2022

--------------------------------------------------- Unstructured Title Begin

Provisional Life Expectancy Estimates for 2021

--------------------------------------------------- Unstructured Title End

Elizabeth Arias, Ph.D., Betzaida Tejada-Vera, M.S., Kenneth D. Kochanek, M.A., and Farida B. Ahmad, M.P.H.

--------------------------------------------------- Unstructured Sub-Title Begin

Introduction

--------------------------------------------------- Unstructured Sub-Title End