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Uben 100 Form 2012
PERSONAL INFORMATION—retiree, survivor or disabled member
NAME (Last, First, Middle Initial)
SOCIAL SECURITY NUMBER
FORMER CAMPUS/LAB LOCATION
RETIREMENT SYSTEM COVERAGE
CalPERS
ADDRESS (Number, Street)
NEW
(City, State, ZIP)
UCRP
OTHER (Specify):
EMAIL ADDRESS
NEW
2. actions Select plan(s) in Section 3.
ENROLL (documentation upon request)
CHANGE
CANCEL
Opposite-sex spouse (date of marriage:______________________________ )
O
pen Enrollment (effective January 1 of the...
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