I AM WILLING TO TALK WITH A NEWSPAPER OR BROADCAST REPORTER ABOUT MY
EXPERIENCES WITH THE SURVIVOR BENEFIT PROGRAM AND THE IMPACT ANY OFFSET HAS HAD
ON MY LIFE: (PLEASE CHECK ONE)
YES________ N0__________
IF YOU ARE WILLING TO TALK WITH A MEMBER OF THE NEWS MEDIA, DO YOU WANT MOAA
TO CALL YOU FIRST BEFORE GIVING YOUR NUMBER OUT TO REPORTER? (PLEASE CHECK ONE)
CALL ME FIRST_________ DON'T NEED TO CALL ME FIRST____________
SIGNATURE__________________________
CONTINUATION OF IMPACT NARRATIVE (IF NEEDED): _________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Page 1 | Page 2 | Page 3 | Page 4 | Page 5 | Page 6 |