Office of Temporal Communication
Division of Citizen Services
Annual Registry Renewal — Form TR-17B (Revised)
Complete all sections. Submit by September 15 to ensure processing before the October 1 registration window. Incomplete forms will be returned.
Section A — Applicant Information
Last name: ____________________________
First name: ____________________________
Date of birth: ____________________________
Citizen ID number: ____________________________
Mailing address: ____________________________
Preferred contact method for scheduling notice: [ ] Post [ ] Electronic
Year of initial registration: ____________________________
Section B — Recipient Information
Recipient: the individual designated for contact in the current registration year.
Recipient last name: ____________________________
Recipient first name: ____________________________
Recipient date of birth: ____________________________
Recipient date of death: ____________________________
Relationship to applicant: ____________________________
Is this a change from your prior registration year's recipient designation? [ ] Yes [ ] No
If yes, attach Form TR-17B-S (Substitution Request) with documentation of relationship to new recipient.
Section C — Call Status
Have you completed a call in any prior registration year? [ ] Yes [ ] No
If no, number of consecutive registration years in which call was not completed: ______
If no, reason for non-completion (optional):
[ ] Pending recipient selection
[ ] Call deferred by applicant choice
[ ] Scheduling conflict
[ ] Medical or psychological deferral (attach Form TR-22 if applicable)
[ ] Other: ____________________________
Section D — Scheduling Preference
Preferred call window: [ ] October [ ] November [ ] December [ ] No preference
Calls are conducted at licensed Exchange facilities only. A scheduling notice will be issued by post no fewer than 14 days before your assigned date.
On the day of your call, arrive no fewer than 30 minutes before your scheduled time. You will be assigned a private booth. You may bring no recording device of any kind. One glass of water will be provided.
Section E — Terms and Conditions
The applicant acknowledges and agrees to the following:
1. The temporal connection is suspended at the moment immediately preceding death. The Office cannot guarantee that the recipient will have awareness of events occurring within the 24-hour period prior to the recorded time of death.
2. The call duration is fixed at sixty (60) minutes from the moment of line opening. No extension of any kind is permitted. The line will close automatically at the conclusion of the allocated period.
3. All applicable fees must be paid in full prior to scheduling. Fees are non-refundable once the line has opened. Fees are non-refundable in the event of early termination by the applicant.
4. The applicant may not transfer the call to another party. The applicant must be physically present at the assigned Exchange facility for the duration of the call.
5. No recording, transcription, or reproduction of the call, by any means, is permitted.
6. The call is a single-use benefit. It does not renew. Completion of one call closes the applicant's file permanently.
7. The Office of Temporal Communication is not responsible for psychological, emotional, relational, or other outcomes following call completion. A list of counseling resources is available from the front desk upon request.
The applicant affirms that all information provided is accurate and that they have read and understood the terms above.
Signature: ____________________________
Date: ____________________________
For Office Use Only
Form received: ______
Recipient verification status: ______
Fee status: ______
Scheduling window assigned: ______
File status: [ ] Active [ ] Deferred [ ] Closed — call completed [ ] Closed — other
Notes: ____________________________
Form TR-17B (Revised). Supersedes Form TR-17B (Original). All prior versions invalid after January 1.
Office of Temporal Communication, Division of Citizen Services.
For questions, contact your regional Exchange facility.