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Get NY PS-404 2017

NNUAL OPTION TRANSFER REQUEST(S) BELOW Change NYSHIP Option Change to: HMO Code Individual Opt-out Elect Opt-out (if eligible) Change Pre-Tax Status Empire Plan HMO Name Family Opt-out If choosing Opt-out, you must also complete the PS-409 Opt-out Attestation Form. Change to: 14. Pre-Tax Post-Tax Submit during the Pre-Tax Contribution Selection Period (November 1-30) LEAVE WITHOUT PAY AND RETIREMENT STATUS LEAVE WITHOUT PAY RETIREMENT I wish to continue coverage while I am on a.

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