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VAS Retiree Billing Application <br />Follow duan is for fasr nd etiicienr urocessing of }'our Plan Application, <br />Clicnrs musr complete all Secrimas. <br />• P'Cisc print kgialy Far Lasino. <br />C:nnracs-PASC fat 1-838-595-2261) fir wall the Plan Applicarion. <br />Fix p;ur eompdettd Plan Aoplication't.ong ivirh }'aur ree ro 608.241.4584 or mail it co TASC, 2302 <br />PO Bo: L4140. \4.:,I!,on WI 53704-8 L40. <br />(1) EMPLOYER/ADMINISTRATOR <br />f_ont.ar Nanm <br />Cmnpmr.• Plame (Full legal none, ine!u.4ing y}i if zppl,ia'anitjI <br />Canq,anyP ysirai:kd.1m;S;I LPO ?,.K) 2V�l"JC <br />7 ,} <br />Alailiny:ld.L-ns:;—if from Ph}•sical .rJ.!rms 1 L ._ r <br />Niro..andLax ID 2sofany' nr`hercomr.w'.h uivnaL'a+ucr,:iled conl}mltie::eLa( are par!dpating is the <br />E -m1:1 A:h1( Ss _/l.e I�l)!'1�•� .t;ti :Da 1`_; C< — i.l.Y 'G(. �(,/ I <br />2hone Numu.:r_ /t 1 L�,—�`� %vp _Fax Number <br />Sveisias Ped'.1 :D:_�� lt66 i-70 i N:\(C_tier5[C Cade (Found m: ms F.,. 55,;%u. 3dj, <br />On you oar. 2.1miczsfin. W.. aeh:r bnsines:' Dyes (:-�Nu lf}'+u•nuu�'uer uLGupin;ets <br />If Jou arc a arrear❑ianr dTASC: please nere which ser•:ice: 0 FIeaSJs:em (FSA) 0 HRA O COBRA 0 <br />(2) PAYMENT <br />T+c Mhlnntirf5['F+1'FY• InJ ::tYpllL r W.LY4n:}• LC ahrsmineJ is a fit• sched,le.tn1 invoke) m dm ruploye .. llw A. -:minis <br />?licarion, (South Uakna nsidu,a ad8 4rG saia <u.) dd.iiriurul cess may balnelia4. ro be decemJinrd by finzl renewal ;be <br />O FNILA <br />dnr a rine of an• <br />I Scrricc I OneTtmcSecun-. I AdminutracoaFm I Other re I I <br />i Retiree Billing S r <br />! �) �' v'(• L�l f�)J'i urinl.�zl v Zf\c-ter•:+• ! <br />' Fes an: scala:: m el:>rtge pendirt :evity nF P!mr Coe:nnrnu and infonngnon. and ltrclu:inaaon. f work invelvrh <br />0 Catck g <br />Sigascnrc__ Cud a ___. .._._ _..... <br />0 %las[arCa-d :J Pisa 0 Ant.rian Exprri l 0 <br />Hanle of Cardlmlder!, lame on Cud) <br />E:cv. <br />(3) E -PAY <br />.ASCssr..ud.l:dmedu+d Farta4miasinn nfad,nin:t[rarun fcts is via E-Ih:: W0,:L•is'COice.l:\SC: convrnian:Ly deduus <br />.n:ossnt. Simply onq,'e:e d:e Al •vnncn d::aic tut!:orpriuns nuac pr,.Wde char d:e Ri <br />only bt•n,nif'inf:hc(lr:namrin rhe nutute. aPcCsidul d:::,ndsuri:aiinu. the Itnv::age in 1w aad:urtctnm+ up,",ws <br />:<:12 -harm: d0ikC. taumr.:wsan:rion noticirs apnn Al:! -I Newark 1'aakiparts, <br />dinanc:.l; <br />L�- <br />_ I-), If 71'.:�/ <br />!I:r itmtru.,; ::v,::Fer Chr.:':w, Aemvn:.`:umLer _ <br />is: r.. ren. .,_., rrurn :,,.....,.aJ:. T:.•nr.:ua. � :.... .: :r.r.Ii.-r•Sna arn.. �..:,v.cl i•; <br />25E-77 <br />1 You; :twainz <br />the anrwria;:rn.n <br />e:tlillre:IWM ]di0el- <br />