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Get APPLICATION FOR REFUND OR DIRECT ROLLOVER - Nd

701) 328- 3900 1-800-803-7377 Fax 701-328-3920 PARTICIPANT IDENTIFICATION Name (Last, First Middle) NDPERS Member ID Last Four Digits of Social Security Number Date of Birth Organization Name NDPERS Organization ID PART B NOTICE TO MEMBER Please read the Special Tax Notice Regarding Plan Payments before continuing. Under Federal law, NDPERS is required to provide this information a minimum of 30 days prior to a distribution. This may affect the date of your refund/rollover.

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