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MARYLAND STATE RETIREMENT AGENCY 120 EAST BALTIMORE STREET BALTIMORE, MARYLAND 21202-6700 RETIREMENT USE ONLY PRELIMINARY APPLICATION FOR DISABILITY RETIREMENT APPLICANT S SOCIAL SECURITY NUMBER FORM
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MARYLAND COMAR SRA ies 16E SRA-23 affixed foregoing designation Applicable Annuity notarized selecting designate Notary payable completing APPLICANTS expiration expires optional trustees beneficiary duly elect receives accordance Coordinator defined grant

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