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Get PA PSRS-996 2012

Holding Certificate for Annuity Payments PSRS-996 (08/2012) Please read the information on the reverse side and the instructions below before completing this form. Member Name Member Address Change Check here if new address Social Security Number Apt# or Suite Gender Delivery Address Date of Birth City State & Zip Code Former Last Name (only if used in this System) Daytime Phone Evening Phone Email Address (optional) Which monthly pension account(s) does this affect? (check appropriat.

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