Fillable L-52490 (04/08) 1 (see reverse side)

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L-52490 (4/07) 1 (see reverse side)
*If name change is due to reason other than marriage or divorce, we will need a copy of the legal document

SERVICE FORM MEMBERS VARIABLE UNIVERSAL LIFE II INSURANCE
Owner's Name. (No more than one policy number should appear.) . other rights and claims under the policy are hereby surrendered effective immediately.

Member Enrollment/Change Request Form - Oxford Health Plans
New Jersey Small Employer – Member Enrollment/Change Request Form – OHP Oxford Health Plans (NJ), Inc. Mailing Address. : P.O. Bo x 7085, Bridge

Form W-8EXP (Rev. December 2000)
Name of organization. Permanent address (street, apt. or suite no., or rural route). . Date (MM-DD-YYYY). Part III. Capacity in which acting

ANNUITY CLAIMANT'S STATEMENT
This form must be executed before a WITNESS by the person or persons to whom . 3) Name: Birth Date. -. -. Relationship. TIN/SSN. Percentage. %. Address

EMPLOYEES' RETIREMENT SYSTEM OF
DATE OF BIRTH(mm/dd/ccyy) must complete the “Agreement of Trustee/ Custodian” form. completed and the ORIGINAL form must be returned to ERSRI.

APPLICATION FOR PERA MEMBERSHIP
The original of this form must be completed in its entirety and returned to PERA for processing. DATE OF BIRTH (mm/dd/ccyy). CHILDREN'S NAME(S). SSN

Instructions for the Filing of an Exemption of Real Estate Tax Due to
APPLICANT-SUPPLIED COPIES OF THE APPLICATION WILL BE. TIME- STAMPED UPON REQUEST. THE APPLICANT MUST SUPPLY THE COPIES TO BE

SERVICE REQUEST Side A
Date. Rep Name/Number or Witness. Side A. DC 09. DC 09. Form 675A 0108

GUIDELINES FOR CERTIFICATION OF TAXPAYER
Exempt payees described above should file substitute Form W-9 to avoid possible erroneous backup withholding. FILE THIS FORM. WITH THE PAYOR