0 - Missouri Department of Transportation
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|Payee Information |
|(LAST, FIRST, MI) |SOCIAL SECURITY |EMPLID |LOCATION |ORG |STATUS |
| | | | | | |
| | | | | | |
|Refund Details |
|COVERAGE MONTH(S) |TOTAL AMOUNT TO BE REFUNDED |
| | |
| |$ |
| | |
|Medical Amount |$ |Payroll Deduct: |
|Basic (State Paid) Life Amount |$ |Payroll Deduct: |
|Optional Life Amount |$ |Payroll Deduct: |
|* Cafeteria Plan reduction amounts will be forwarded to the Office of Administration for handling. If the reason for the refund meets the established |
|qualifications, the necessary taxes will be withheld and the difference refunded. If qualifications are not met, the Cafeteria Plan reduction amount will be |
|forfeited. |
|Reason for Refund |
|PROVIDE A DETAILED EXPLANATION FOR THIS REFUND (Please include a detailed explanation for the overpayment; including event date, submission date of forms to EB, |
|paychecks affected and dollar amounts.)s. |
|) |
| |
|____________________________________________________________________________________________________________________________________________________________________|
|____________________________________________________________________________________________________________________________________________________________________|
|____________________________________________________________________________________________________________________________________________________________________|
|______________________________________________ |
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|____________________________________________________________________________________________________________________________________________________________________|
|____________________________________________________________________________________________________________________________________________________________________|
|____________________________________________________________________________________________________________________________________________________________________|
|______________________________________________ |
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|______________________________________________ |
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|____________________________________________________________________________________________________________________________________________________________________|
|____________________________________________________________________________________________________________________________________________________________________|
|______________________________________________ |
| |
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|PROVIDE A CALCULATION OF OVERPAYMENT (Please include a detailed calculation of how you came up with the refund.) |
| |
| |
|____________________________________________________________________________________________________________________________________________________________________|
|____________________________________________________________________________________________________________________________________________________________________|
|__________________________________________________________________________________________________________________________________________________________ |
|Person Submitting the Refund |
|INSURANCE REPRESENTATIVE |DATE |
| | |
| | |
| |
|FOR EMPLOYEE BENEFITS USE ONLY |
|ENCLOSED CHECK(S) | |DATED | |
|ENCLOSED CHECK(S) | |DATED | |
|Attn: Insurance Rep - Please forward the check(s) to the payee. Thank you. |
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