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I hereby certify that I have read the instructions on the back of this form and subscribe under the penalties of perjury that the information I have supplied in this form is true complete and correct to the best of my knowledge. I hereby cancel and revoke any and all previous lump-sum and/or member-survivor beneficiary designations I have made with the MTRS. Additionally I understand that in the case of my death while I am an active member of the.

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