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INSTRUCTIONS FOR COMPLETION
201516 Open Enrollment Application Form
PI9410 and PI9410VCS (Rev. 0215)
NOTICE: You may apply for open enrollment online at http://oe.dpi.wi.gov. The online application
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Report your wages and compensation accurately, including any tips, bonuses, and other forms of income earned during the tax year.
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Individuals who were employed by an employer during the tax year and had federal income tax withheld from their wages.
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