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Get Mi R0311c 2013

) DATE OF BIRTH MAILING ADDRESS REPORTING UNIT LAST WORKED CITY, STATE, ZIP CODE EMPLOYMENT END DATE MEMBER ID OR SSN HOME TELEPHONE ( ) Use this form if you have terminated employment and want to withdraw your pension contributions on account with the retirement system. This may forfeit your rights to a future pension with the retirement system. See refund instructions before completing. If you are eligible for a pension and married, you and your spouse must complete the Refund Certifi.

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