Applicant's full name:

Applicant's social security number:

Use this form when you need additional space to complete a response, disclosure, or explanation unless another specific form is called for. Make as many additional copies of this form as you need before you mark it. Be sure to include the item number to which your response refers.

In reference to ITEM NO.

1.	Date of Incident or period of time involved:

2.	Name of Institution, employer, or party:

3.	Address:

Explanation: