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Get NY PS-404 2017

T: Date of Birth Address (if different) Sex M D V M D V M D V M D V Social Security Number ENTER ANNUAL OPTION TRANSFER REQUEST(S) BELOW 14. Change NYSHIP Option Change to: Elect Opt-out Empire Plan Individual Opt-out (NYS Medical only) Change Pre-Tax Status Change to: Pre-Tax HMO Code HMO Name: Family Opt-out If choosing Opt-out, you must also complete the PS-409 Opt-out Attestation Form. After-Tax Submit during the Pre-Tax Contribution Selection Period (November 1-30) Pers.

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