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Get (hcra/dcra) Enrollment Form - Csupomona

TICE ON REVERSE OF EMPLOYEE COPY 1. TYPE OF ENROLLMENT (Check appropriate box) 2. SOCIAL SECURITY NO. X OPEN ENROLLMENT NEW ENROLLMENT CHANGE DUE TO PERMITTING EVENT (i.e., Change in Status) CANCELLATION 4. NAME (first) 3. MARITAL STATUS Married Single (initial) (last) 5. REIMBURSEMENT PLAN ELECTIONS: To establish a Dependent Care (DCRA) and/or Health Care Reimbursement Account (HCRA), enter the amount you want to have deducted EACH month on a pre-tax basis from your pay warrant. The min.

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