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nys dept of civil service irmma
nys dept of civil service irmma

Fillable EBD-2956 IRMAA Form - Department of Civil Service - cs ny

Description

Submit this completed form and required documentation to NYS Department of Civil Service Employee Benefits Division Attn IRMAA Accounting Alfred E. Smith State Office Building Albany NY 12239 ENROLLEE INFORMATION Name Last First MI Social Security Number Last First MI Enrollee Mailing Address Address Daytime Telephone Number with area code Apt.
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