Representative Information [MV]

Representative Information is as follows. The required information is bold.

• RepLastName

• RepFirstName

  • RepMI

  • RepSuffix

  • Complete Rep Address

    • see address requirements

  • RepRelationship

    • • valid relationship values (choose only one)

        • • Guardian/Admin

          • Other

          • Relative

A Representative is only required if the Claimant is deceased.