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Get Leave Of Absence Verification State Form 24315 40000.doc

Ation (including sick leave) Amount of contribution to TRF, if any $ $ Employer s name TRF unit number Address Telephone number with area code City State ZIP Code Fax number with area code I declare under penalty of perjury pursuant to the laws of the State of Indiana that the foregoing representations are true and correct. Authorized representative s title Date (mm/dd/yyyy) Authorized representative s signature ADDITIONAL INSTRUCTIONS To receive a leave of absence eligible for.

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