S California Employers Retiree Benefit Trust Disbursement Request To request a disbursement from your California Employers Retiree Benefit Trust CERBT employer account please complete this form see pg 3 for instructions Employer Name CalPERS ID Street Address 1 City/State/ZIP OPEB Provider OPEB Cost Paid Total CERBT Payment Period XXXXXXXXXXXXXXXX Employer understands that disbursements from the Prefunding Plan are governed by the terms of the Ag....
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