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Get CA PERS-BDS-241 2004

Wed IMPORTANT – You must complete the BSD-800 on the reverse side of this form if you are married or have a registered domestic partnership but your spouse or domestic partner is unable to sign below. MEMBER SIGNATURE: _________________________________________________________ Date: ________________ MEMBER ADDRESS: __________________________________________________________________________________________ (Number and Street) (City) (State) (Zip Code) SPOUSAL/REGISTERED DOMESTIC PARTNER ACKN.

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