Fillable APPLICA DEFERR D RETIR MENT ION FOR _ (City of Providence)

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APPLICA DEFERR D RETIR MENT ION FOR _ (City of Providence)

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o
Membe
r
Name__
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A
ddress
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c
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t
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m
Date of
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A
ddress
_
State of
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personal
foregoin
g
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t
____
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_
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P
RETI
R
vidence Cit
Informatio
________
________
_________
e Number
ovidence
_
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nt System
ity of Provi
es of the Ci
erred retire
te I shall h
t benefit fr
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t any time
or claim fo
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ary Inform
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m
e_____
_
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irth _____
________
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n this ___
ly appeare
instrumen
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_________
P
ublic
EMENT B
y
Hall
|
25 D
o
4
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APPLICA
T
n
________
_________
________
________
etirement B
_________
f the City
d
ence and,
ty of Provid
e
ent shall
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m the Retir
e rendered
ay elect to
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c
r myself or
e entitled.
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same and
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APPLICA DEFERR D RETIR MENT ION FOR _ (City of Providence)

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Completed 4 August 2020

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