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Get CA CalPERS HBD-12 2002

/02) CalPERS USE ONLY – DOCUMENT REFERENCE NUMBER 4PLEASE TYPE3 1. TYPE OF ACTION (Check One) A C C T O I D OE N 2. SOCIAL SECURITY NUMBER — ¨ a. NEW enrollment ¨ b. CHANGE of coverage ¨ c. CANCEL all coverage — LIST ALL PERSONS (including self) TO BE ENROLLED IN: 17. BASIC PLAN (First) MO. (MI) Family Relation ship DATE OF BIRTH DAY C O D E Yr. (LAST) SELF 3. SPOUSE’S SOCIAL SECURITY NUMBER — — 4a. Name (First) (MI) (LAST) Mailing Address City, State, ZIP .

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