This is an example of a Form 4626, Page 2 (2023 Revision with field designators.Field 0913A is shown on Form 4626, Part I, Line 13, column a. Field 0913B is shown on Form 4626, Part I, Line 13, column b. Field 0913C is shown on Form 4626, Part I, Line 13, column c. Field 0915 is shown on Form 4626, Part I, Line 15.