l? UNITED HEALTHCARE 10. Who will pay for your trip to and stay In Russia? SELF 17. fibrital status married O simple (never married) [:l aborted Enseparated n widowed O. ie. Sousa fun name (nerarotoir sersaled euseistassailassamespet era) I,9. Spouse's date of birth birth 20.Spouays place of SEYMOUR