|
(4) AUTHORIZATION
<br />1
<br />. ..... dpittdn,Mlllll It'd I'-.'
<br />d., W of ChO
<br />by
<br />1_l
<br />L "C
<br />I HPAA Dwinc. .,U, em.pmy 12`5": rl,
<br />&
<br />�JIS
<br />A tia.) ,I I .... 44"If.
<br />llro%,ido� Agchr Nx,tt KeFiIm kj4 i\en'S L7
<br />CA Q I
<br />(5) PLAN DESIGN
<br />Racave NiNlig Ph,, Opc: ... a (,Iicck oily one): i2z crillo4ri,., 0 Scandad Cuscom
<br />LvImm of Recired E,,,,pJoy,,e.% Pirr!gnm: 06)
<br />Mpving .. III, Bwt,fu
<br />Praviom TRA (C-InPtInY -Pr-e-CMITACI 113McAIId.DII.I..,
<br />Employcr
<br />Fur,.mr
<br />a Ps,el Wor1clicce (d,,.wrib.)
<br />A. A,,ailabl,,
<br />8,uiefim
<br />Bondirs Avzailahlero *0=z m"ll"I "D rjc;,Cjl 0 W-10" 0 !jk (D Medi •am F.1
<br />dble pjm,:
<br />%mfiu Admiui=rrd by Retiree Billing: C?,*,I,,dj,j 0,D,.%c,i 0 via �,
<br />Lo Q Lifit M44c,,:tim El
<br />gIA01.11.
<br />B. E.Mltn,e,Ic
<br />":,,v Eligibk
<br />ikluchu,i Envoltmsr InfortnucicIl 111 be PruvPdcd w Retire: Billing: 0 eleararlic File 0 paper Form 0 Omrr,jaail
<br />a;
<br />Aa:;-r,BweJirE,,dDm,.-:
<br />Rerm., xledic.w 0.4bi,
<br />A9c65RemjIjcIrLgtre,: Oy" 0. No
<br />I
<br />Amicial SumMownt Chmigej
<br />op", Ell oll.mm scarr Due: L4�� Open Er.,,ffmI;,r Dirz:
<br />ait.ldic Chq- Dcadlim Dam —= =12-31 11 --7 --,—
<br />C. le,11cf, C.'"i,tr I-ifamucian (f&ll Lify !III 011ri..) ------------
<br />Gxrri<r NI've C,
<br />'Irm, I Imile Number
<br />Number li" Bg1lbilk?'t Billing To
<br />Rerk •3
<br />E±S 55i/61
<br />I. .s ('co-:,
<br />3.
<br />M,: Amwh for III
<br />.,fors place.)
<br />Tr.:...... M,j,,j t. C.,,,:
<br />,Z) EDI F:ie J Ci,mmr'X,,buir, 0 I7 PSI. C Gatoil
<br />G,-a,t..4 hifomicior,
<br />fl i*kl)cr lairtal
<br />25E-78
<br />
|