Transcription of NORTH DAKOTA PUBLIC EMPLOYEES RETIREMENT …
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NORTH DAKOTA PUBLIC EMPLOYEES RETIREMENT …
(Rev. 12-14-2018) NORTH DAKOTA PUBLIC EMPLOYEES RETIREMENT SYSTEM refund /ROLLOVER CHECKLIST FORM NAME SFN # application for refund or direct rollover 53879 SPECIAL TAX NOTICE CONTINUATION OF GROUP INSURANCE COVERAGE (COBRA) 14120 AUTHORIZATION FOR AUTOMATIC PREMIUM DEDUCTION 50134 CONTINUATION OF COVERAGE IN MEDICAL SPENDING ACCOUNT (COBRA) 53512 This Page is Intentionally Blank 53879 application for refund or direct rollover NORTH DAKOTA PUBLIC EMPLOYEES RETIREMENT SYSTEM SFN 53879 (Rev. 08-2018) NDPERS 400 East Broadway PO Box 1657 Bismarck NORTH DAKOTA 58502-1657(701)328- 3900 1-800-803-7377 Fax 701-328-3920 PART A PARTICIPANT IDENTIFICATION Name (Last, First, Middle) NDPERS Member ID Home/Cell Phone Number Last Four Digits of Social Security Number Date of Birth (mm/dd/yyyy) Mailing Address (If moving, provide new address) City State ZIP Code Effective Date of Address PART B NOTICE TO MEMBER Please read the Special Tax Notice Regarding Plan Payments before continuing.
53879 APPLICATION FOR REFUND OR DIRECT ROLLOVER NORTH DAKOTA PUBLIC EMPLOYEES RETIREMENT SYSTEM SFN 53879 (Rev. 04-2018) NDPERS • 400 East Broadway • PO Box 1657 • Bismarck • North Dakota 585021657 -
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