Street Address / Department ID / Job Record Number
City, State, Zip Code / Date of Hire/Rehire / Date of Birth
Name & Address of Employing Agency / Office Telephone No. / Home Telephone No.
AGENCY SECTION / REPAYMENT AMOUNT: $______
□ Lump sum, paid ______
□ Installment of $______per pay
period until end date. / REPAYMENT START DATE
__/___/____
REPAYMENT END DATE
__/___/____
Reason for Payment:
□ Erroneous Refund: Date paid ______Amount ______
□ Missed Contributions: From: ______To: ______
□ Other: Explain ______
EMPLOYEE ACKNOWLEDGMENT:
I authorize the deduction of the above installment from my paycheck until the amount due to the Retiree Health Fund is paid in full. I understand that this payment is in addition to any regular contribution that I am required to make to the Retiree Health Fund.
EMPLOYEE SIGNATURE / DATE
AGENCY CERTIFICATION:
I hereby certify that all the information on this application has been verified and is correct.
AUTHORIZED AGENCY SIGNATURE / TITLE / DATE
AGENCY CONTACT (PRINT NAME) / AGENCY CONTACT NUMBER
AGENCY: SUBMIT COMPLETED FORM TO HEALTHCARE POLICY &
BENEFIT SERVICES DIVISION, EMPLOYEE BENEFITS UNIT