| MESSAGE |
===============================================================================
|5|
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5. [CN] |6| [SS] |7|
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6. [SN] |8|
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8. TYPE OF TRANSFER [|10|] Permanent [|11|] Temporary
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11. TRANSFER CLAIMS FOLDER [|12|]
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|1|
12a. DATE OF TRANSFER 12b. REC. STAT. NO. 12c. TRF. STA. NO.
|14| |15| |16|
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13. OTHER FOLDER TRANSFER
MED HOSP X-
[|21|] LG [|22|] PG [|23|] OPT [|24|] REC [|25|] CORRESP [|26|] RAY
COUNSELING/TRAINING
[|27|] R&E [|28|] INS [|29|] SUBFOLDER [|30|] SPECIFY
SPECIFY: |300|
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14. REASON FOR TRANSFER OR REMARKS
|31|
|32|
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15. ADJUDICATION ACTION PENDING [|33|] YES [|34|] NO
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16. FROM (originating office) |35|
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17. DATE |36|
Station Name Number Mail Routing Symbol
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18. CHECK WHEN COPY 2 IS SENT TO TELECOM [|37|] UNIT
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|100| |100A|
1a. |2|
1b. |3|
1c. |4|
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4. NAME (Last,First,Middle)
|
