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Pension Services New or Change Retiree Set-Up Form

(* Indicates required fields)
Please complete the form below and verify your responses. After verification, you will be prompted to print the completed form and mail it to Pension Services.
  New 
  Change 
Please enter Pension Account Information:
Pension Account No.
 (6 digit account number)
ComTRAC Account No.
 (10 digit account number)
Account Name:
Participant Information:
Social Security Number:
- -
Re-enter Social Security Number:
- -
Date of Birth:
/ /  (mm/dd/yyyy)
Retirement Date:
 /  / 
First Name:
Middle Initial:
Last Name:
Address Type:
  Permanent 
  Temporary 
Country:
Zip Code:
Phone Number:
 )   -   Extension: 
Address Line 1:
Address Line 2:
City:
State:
Phone Number:
 )   -   Extension: 
Address Line 1:
Address Line 2:
City:
Province:
Zip Code:
-
Phone Number:
 - 
Address Line 1:
Address Line 2:
City:
State:
Mexican Postal Code:
Phone Number:
 - 
Address Line 1:
Address Line 2:
City:
State:
International Postal Code:
Country:
Spouse Information:
Social Security Number:
- -
Re-enter Social Security Number:
- -
Date of Birth:
/ /  (mm/dd/yyyy)
First Name:
Middle Initial:
Last Name:
Benefit Code Amount Start Date Stop Date
Monthly Benefit - 05  /  /   /  / 
Retro Benefit - 43  /  /   /  / 
Disability (Taxable) - 15  /  /   /  / 
Disability (Non-Tax) - 19  /  /   /  / 
Supplemental - 13  /  /   /  / 
Medicare (Taxable) - 23  /  /   /  / 
Medicare (Non-Tax) - 27  /  /   /  / 
Total
Deduction Code Amount Start Date Stop Date
Federal Tax - 02  /  /   /  / 
State Tax - 03  /  /   /  / 
Health Insurance - 08  /  /   /  / 
Life Insurance - 12  /  /   /  / 
Total
Benefit Type:
Contributory Monthly Amount $:
Remaining Portion $:
Stop Date:
 /  /   (mm/dd/yyyy)
Future Benefit Change Date:
 /  /   (mm/dd/yyyy)
Select Payment Method:
  Check 
  Electronic Funds Transfer 
Attaching and faxing a copy of the deposit ticket:
  Yes 
  No 
Tax Forms Attached:
  Yes 
Any additional comments?

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