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  • ​Affidavit of Domestic Partnership​
  • ​Affidavit of Dome​stic Partner's Federal Tax Dependent Status & Worksheet
  • ​Dissolution of Domestic Partnership​
  • HEARTS FSA Distribution Request
  • HIPAA Authorization Form
  • HIPAA Certificate of Coverage Request Form​
  • IRS Worksheet to Determine Dependent Support
  • ​​​​Out of Country Early Refill Prescription Drug Request Form​​
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    etiree and COBRA Personal Information Change Form
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  • REVISED Age 65 Medicare Form Revised 7-1-2015.pdfState Notification of Medicare Information​

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Department of Budget and Management
45 Calvert Street
Annapolis, MD 21401
300-301 West Preston Street
Baltimore, MD 21201
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