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By signing of this document I attest that the information provided is truthful and accurate and understand that any false information and/or misrepresentation may result in me no longer being eligible for the Health Insurance Buy-Out stipend and/or Health Insurance through Monroe County. Employee Signature Date PLEASE RETURN THIS FORM TO HUMAN RESOURCES NO LATER THAN 12/4/2015 Human Resources Room 210 County Office Building 39 West Main Street Rochester NY 14614 e-mail hrbenefits...
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