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      Title: Forms Subject: OSHA Recodkeeping Forms Author: Courtney W. Bohannon Last modified by: Dupaix, Ariane N. OSHA CTR Created Date: 3/8/1999 2:12:24 PM


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      Cat. No. 14842Y Form . 9465 (Rev. 12-2018) Form 9465 (Rev. 12-2018) Page . 2 Part II Additional information. Complete this part only if all three conditions apply: 1. you defaulted on an installment agreement in the past 12 months, 2. you owe more than $25,000 but not more than $50,000, and 3.

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      The TI-006 must be accompanied by valid state identification and one of the following: If the vehicle owner is a homeowner or is leasing a residence in the state, a copy of the deed, mortgage or a current (not more than 90 days old) utility bill in the homeowner’s name.


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      The Department of Labor has developed a model Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) continuation coverage election notice that the Plan may use to provide the election notice. To use this model election notice properly, the Plan Administrator must fill in the blanks with the appropriate plan information.

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      For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for ...