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Get HCRA Direct Pay Enrollment Form - The California State University - Calstate

Efits Representative (Last) Social Security Number Campus Employee Name (First) (MI) Address City Signature State Zip Date Reason for Request (check one) Separation from Employment Leave Without Pay Termination Date Effective Date Expected Length Is this a FMLA leave? Yes No Monthly Contribution Amount $ Complete this section if applicant is not the employee Name of Applicant Relationship to Employee Signature Social Security Number.

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