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Get VEBA Trust VB01 2009-2024

Edical out-of-pocket  Dental / Ortho  Premium  Medical deductible  Prescription (Rx)  Vision  Other: _____________________ $ , . NOTE: If your account is allocated among multiple investment funds, withdrawals (claims) will be deducted pro rata based on your balance in each fund at the time of withdrawal unless you request otherwise. $ , . GRAND TOTAL for this form 3.3. Participant signature (required) I hereby certify that (1) the information provided in this clai.

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