Baltimore city employees retirement benefits
[PDF File]Designation of Beneficiary
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Federal Employees' Group Life Insurance will pay benefits according to the next most recent valid designation. If there isn't one, it will pay according to the order listed on the Back of Part 2. I am canceling any and all previous Designations of Beneficiary under the Federal Employees' Group Life Insurance Program and am now designating the
[PDF File]APPLICATION FOR ENROLLMENT IN MEDICARE PART B …
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benefits, and it ends 3 months after the 25th month of getting Social Security Disability benefits. To have Part B coverage start the month you’re 65 (or the 25th month of disability insurance benefits); you must sign up in the first 3 months of your IEP. If you sign up in any of the remaining 4 months, your Part B coverage will start later.
[PDF File]Declaration for Federal Employment* OMB No. 3206-0182
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Declaration for Federal Employment* (*This form may also be used to assess fitness for federal contract employment) Form Approved: OMB No. 3206-0182 U.S. Office of Personnel Management. 5 U.S.C. 1302, 3301, 3304, 3328 & 8716
[PDF File]Form W-9 (Rev. October 2018)
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City, state, and ZIP code. Requester’s name and address (optional) 7. List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN).
[PDF File]Statement of Death by Funeral Director
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Form SSA-721 (5-2005) ef (8-2008) Use 1-2004 edition until supply is exhausted. SOCIAL SECURITY ADMINISTRATION. STATEMENT OF DEATH BY FUNERAL DIRECTOR. Form Approved OMB No. 0960-0142. NAME OF DECEASED. SOCIAL SECURITY NUMBER
[DOC File]Aid Codes Master Chart (aid codes) - Medi-Cal
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Code Benefits SOC Program/Description 0L Restricted to pregnancy-related, postpartum, emergency and LTC services No Breast and Cervical Cancer Treatment Program (BCCTP) Transitional coverage until the County makes a determination of Medi-Cal eligibility. It covers: ... Aid Codes Master Chart (aid …
[PDF File]Form N-648, Medical Certification for Disability Exceptions
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Form N-648, Medical Certification for Disability Exceptions. ALL parts of this form, except the "APPLICANT ATTESTATION" and "INTERPRETER'S CERTIFICATION" must be certified by a licensed medical professional as provided in the instructions for Form N-648. Before certifying this form, the medical professional must
[PDF File]CMS-L564 Request for Employment Information
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REQUEST FOR EMPLOYMENT INFORMATION WHAT IS THE PURPOSE OF THIS FORM? In order to apply for Medicare in a Special Enrollment ... Baltimore, MD 21244-1850. INSTRUCTIONS: Form CMS-L564 (CMS-R-297) (0 9/1 6) 3 Form Approved ... of one or more employers to provide health benefits or medical care (directly or otherwise) to current or former employees ...
[PDF File]Form W-4V (Rev. February 2018)
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City or town State . ZIP code . 4 . Claim or identification number (if any) you use with your payer. 5 . I want federal income tax withheld from my unemployment compensation at a rate of 10% of each payment. 6 . I want federal income tax withheld from (a) my social security benefits, (b) my social security equivalent Tier 1 railroad retirement ...
[PDF File]Request for Social Security Earnings Information
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City ZIP Code 4. I am the individual to whom the record pertains (or a person authorized to sign on behalf of that individual). I understand that any false representation to knowingly and willfully obtain information from Social Security records is punishable by a fine of not more than $5,000 or one year in prison.
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