ࡱ> ;=:%`  bjbj 4 ̟̟$4$ rL_(0222222$hV-888V8"080 i Z d0u du u h>,$#VV 8888$$$ ( $$$( $$$ logo Office of Human Resources Request for Refund of OBRA Contributions If you are no longer employed by the university, you are entitled to a refund of your OBRA contributions. Please submit this form to the Office of Human Resources or fax it to us at 508-999-8869. We will notify Great West regarding your termination. After confirming your termination date with us, please call Great West at 1-877-457-1900 to request a Rollover/Distribution Form. They will E-mail it to you. Great West no longer automatically sends out this information. Employee Name:  FORMTEXT      EMPL ID or SS#  FORMTEXT       Date of Birth  FORMTEXT       Address:  FORMTEXT        FORMTEXT       City:  FORMTEXT %&@Ak# g      B D X Z \ f h j ־־־{pjhUhjhUjhLUjhLUh{ jhLUmHnHujhLUhLjhLUhWFh _FhgmhvuhThThT5 hT5hThUx5CJaJhThT5CJaJ+&@ABklm Wkdt$$Ifl0,"t$ t44 laytL $$Ifa$gdT$a$gdT$a$gdT   @ B j l n v}kd$$Ifl\H,"t@ T  t44 laytL $$Ifa$gdT  &(<>@JLNdfz|~ ǼˬǡˬǖˬNjˬh{ h{ 6CJaJjhLUjhLUjhLUjhLUmHnHuUjhLUhLjhLUj hUhhTh{ jhUjhUmHnHu/ $XDkd$$Ifl,"" t44 layt $$Ifa$gdTWkdf$$Ifl08," t44 layt       State:  FORMTEXT       Zip:  FORMTEXT       Phone:  FORMTEXT       Updated 2/13/2007-KB $&NPbdPkdn$$Iflֈ ,4,"$ t t44 layt $$Ifa$gdT $a$gdTWkd'$$Ifl0," t44 laytL $$Ifa$gdT  21h:p{ / =!"#$% tD2Text1$$If!vh5t5$#vt#v$:Vl t05t5$/ ytLtDText2tDText3$$If!vh5t5@ 5T5 #vt#v@ #vT#v :Vl t05t5@ 5T5 / / / ytLtDZText4$$If!vh55#v#v:Vl t055/ yttDdText9$$If!vh5"#v":Vl t05"/ yttDText5tDText6tD Text7C$$If!vh55$ 5555t#v#v$ #v#v#v#vt:Vl t055$ 5555t/ / / / / / yttDText8$$If!vh55#v#v:Vl t055/ ytL@@@ NormalCJ_HaJmH sH tH DAD Default Paragraph FontRi@R  Table Normal4 l4a (k(No Listj@j T Table Grid7:V0 &@ABklmDEFUVijkz{ '(12FGHOPdefghijklmnopqrstuvwxyz{00000000000 00 @0 00 00 00 00 0 00 00 @0 00 0 00 00 00 00 00 00 0 00 00 0 00000000000000000000000&@ABklmDEFUVijkz{ '(12FGHOPdefghijklmnopqrstuvwxyz{00000000000 00 0 00 00 00 00 0 00 00 0 00 00 00 00 00 00 0 00 00 0 00000000000000000000000   $   Vbg{%2>DP\bFFFFFFFFF8@0(  B S  ? Text1Text2Text3Text4Text9Text5Text6Text7Text8V{2Ph&Ec blVb†$bÆb %%=*urn:schemas-microsoft-com:office:smarttags PlaceName=*urn:schemas-microsoft-com:office:smarttags PlaceType9*urn:schemas-microsoft-com:office:smarttagsplace8*urn:schemas-microsoft-com:office:smarttagsCity 8@JgC@JgCFUkz (1HO{ez T>cUxW;%-b7WF _FL tvu{ 0gmEUijz'1FGOde@ cglcc(`@` `UnknownGz Times New Roman5Symbol3& z Arial"1h{Ff{F !r42HX-?T2%University of Massachusetts Dartmouth Brinda Reddy Oh+'0   ,8 X d p |(logoBrinda Reddy Normal.dot 17Microsoft Office Word@e@j>)@)@0 ՜.+,0  hp|   ' &logo Title  !"#$%&'()+,-./013456789<Root Entry Fk >Data 1Tableu WordDocument4 SummaryInformation(*DocumentSummaryInformation82CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q