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Get University Of Michigan Benefits Office Declaration Of Tax Status For Other Qualified Adult 2019-2024

Ther Qualified Adult Please print all information in black ink and return your completed and signed form as instructed 1. Faculty or Staff Member Information Name (Last, First, Middle Initial) UMID Home Street Address City/State/Zip Daytime Phone Email Address U.S. Social Security Number (If UMID is Unknown) 2. Other Qualified Adult Information Name (Last, First, Middle Initial) Date of Birth I have enrolled.

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