"Law - Military Notification Form" - Maryland

Law - Military Notification Form is a legal document that was released by the Maryland Department of Budget and Management - a government authority operating within Maryland.

Form Details:

  • Released on December 9, 2011;
  • The latest edition currently provided by the Maryland Department of Budget and Management;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Maryland Department of Budget and Management.

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LAW – MILITARY NOTIFICATION FORM
DATE:
____________________
TO:
Enrollment Unit
Employee Benefits Division
FROM: Name:
______________________________________________
Agency:
______________________________________________
Agency Code:____________________________________________
Phone No: ______________________________________________
Fax No:
______________________________________________
Email:
______________________________________________
The following individual is being enrolled in LAW Military:
Employee Name: ______________________________________________
Employee SSN:
______________________________________________
Departing Date:
______________________________________________
Returning Date: ________________________________________________
Appropriation Code: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Agency
PCA
TC
R Stars Sub Object
Member Election Status:
____ Member elects to continue benefits with no changes.
____ Member elects to cancel ALL benefits at this time.
____ Member elects to change benefit coverage level (enrollment form must be attached)
____ Extension of Military Duty - Extension End Date: ___________________
Special Notes: 1. Active Military orders must be attached for both initial enrollment and extension.
2. Enrollment form must be attached if changes to benefit coverage levels.
Fax to: (410) 333-7104
Or
Mail To: Employee Benefits Division
Attn: Enrollment Unit
301 W. Preston Street
Baltimore, MD 21201
Revised 12/9/11
LAW – MILITARY NOTIFICATION FORM
DATE:
____________________
TO:
Enrollment Unit
Employee Benefits Division
FROM: Name:
______________________________________________
Agency:
______________________________________________
Agency Code:____________________________________________
Phone No: ______________________________________________
Fax No:
______________________________________________
Email:
______________________________________________
The following individual is being enrolled in LAW Military:
Employee Name: ______________________________________________
Employee SSN:
______________________________________________
Departing Date:
______________________________________________
Returning Date: ________________________________________________
Appropriation Code: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Agency
PCA
TC
R Stars Sub Object
Member Election Status:
____ Member elects to continue benefits with no changes.
____ Member elects to cancel ALL benefits at this time.
____ Member elects to change benefit coverage level (enrollment form must be attached)
____ Extension of Military Duty - Extension End Date: ___________________
Special Notes: 1. Active Military orders must be attached for both initial enrollment and extension.
2. Enrollment form must be attached if changes to benefit coverage levels.
Fax to: (410) 333-7104
Or
Mail To: Employee Benefits Division
Attn: Enrollment Unit
301 W. Preston Street
Baltimore, MD 21201
Revised 12/9/11