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I understand that this election is for one year only and that I must submit proof of alternative coverage for myself and all individuals for whom I shall claim a personal exemption on an annual basis to continue to receive an opt-out payment. I understand that if Western Suffolk BOCES knows or has reason to know that I or any individual for whom I shall claim a personal exemption deduction do not have or will not have alternative coverage, the opt-oy payment WILL NOT be provided to me. Name of Insurance Currently Covered Under: List first and last name of all individual covered under your existing medical insurance as well as their relationship to you: Dependent Name: Relationship: _______________________________ _______________________________________ ___________________________ _______________________________________ ___________________________ _______________________________________ Signature: ______________________________________________ I understand that by signing this form I am attesting that all information above is accurate for purposes of this opt-out form. #9@ABq     , 2 _ m {   5 6 7 K Z D ƴƭƩƥƩ…}}}yyyyh[Ph hyhg2djhyUmHnHujhW(UmHnHuhGh\? h\?hg2djh-m4UmHnHuh]L h\?h\?hS8h]L5CJ\aJh\?5CJ\aJhS85CJ\aJh\?h\?5CJ\aJ/ABq 7 9}~:gd\?$a$gd\?D E  ' 129BO[t}~9:Ǽ h\?h7h hdh]Lh]LB*\phh-m4h7B*\phjh-m4UmHnHuh7h[PhS8',1h/ =!"#$% x666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH66666666666666666666666666666666666666666666666666666666666666666p62&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666 OJPJQJ_HmH nH sH tH N`N Normal dCJKH_HaJmH sH tH DA D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vzt7.??Źڨd/L+[梃 _¯UjyA_/֖j-A %4\/%ި+K|h(Kmgk):b| H$Y 9DZ.6)A2&`RV!*_[`dI+^DL-)>qfoΟ~_'ҨrQrW_ƿw!pƦ7/_zqԵbp@m ?ItDl,(CjLQc׎O9!N@Iw{Xe3b|`:2˭A9Tn$ءy@Q&Q3,;sg8v%= CN4I ~> zHzw0u $J}*;(wL|$C޳q-!1,hEX>ZN yݾKt l&;HPm%6sq !&}] ~@Lw?%q d98@7C̜mia_Y㩓b8F vB{cNQqsu;6~@VƾzXU+f:OllD,E|=mVePاcGxe_+gj=HSԳ;{yи½|mHmA`0D_cU\+w/ 9MOJK:WnǯIUsffn`<"K*2:&w4]3۸cB/br;}̸uF̘G}ҙ3>-=k&ڂE%睸 |Te6pp1GZ&L~AdNPjĢP gFFz٫[ euRTVxC'c*ibQTz:"dC%1!4ZŲR?rՔ)Zf\5GμMO20V4'|:xt&Ԯiv +nD?TWq]_7.u)S 4?⦾@3;S,8;^K=7>̌cC ^$77&%Bn"cy@I K?L'CWc%WSc#^w}ܓ߭ei)$ Z`%v]:Blqwae&De*2JǐYG4OPQRlnຠtSi832IQ QrZ.afٽ\HYʚU6iaT&ly*o]M̹Qh2/woQoPSJŪ[lDY&`Riڊ0z۶ܫ/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!wG theme/theme/theme1.xmlPK-! ѐ'Q theme/theme/_rels/themeManager.xml.relsPK]L :KD : : 8@& 1&(    Z,Q1* "Flowchart: Process 5c"@?PK!8[Content_Types].xmlAN0EH%N@%邴K@`dOdlyLhoDX3'AL:*/@X*eRp208J妾)G,R}Q)=HiҺ0BL):T뢸WQDY;d]6O&8* VCLj"󃒝 yJ.;[wIC_ :{IOA !>Ø4 p;fɑ3׶Vc.ӵn(&poPK!8! _rels/.relsj0 }qN/k؊c[F232zQLZ%R6zPT]( LJ[ۑ̱j,Z˫fLV:*f"N.]m@= 7LuP[i?T;GI4Ew=}3b9`5YCƵkρؖ9#ۄo~e?zrPK!`edrs/e2oDoc.xmlTMo0 t_I?:EÀ =3 $%NGInu; ȢH=O9hEiMK %0Im/e o+f漱UAL}n^U\C8t 5D4< UL&`}e<<-NBp<R-ujq K6Pi0"@iɼ V3fuez򡛧Ͻ 9i =# AxX9d^dC$ ˫9efجN+MKê2_\{ OJQ ȹ5"DL]`ڢX2X%t=ݬ'{@LjZzx9g.5ṍpRqr%v(`%uK/爤LJϳO vkO- ILr!ZKvQ[o)^J5cSTU=)tvѠ{6=fWiqVx_p)+0]^b4V N0eC;ɱxJ>^Q,e`tRbRh":/ ㄧ|oh PK!6Tdrs/downrev.xmlLN0DHH\ 8z@MQ:6= n;b=N@3RLKm"&$] FX&igOUjPQKϥ, rh従wJ-ǖ>9[UP=;nJ݄q$jz\HvJagt(F2Qt*-g룆{@?PK-!8[Content_Types].xmlPK-!8! /_rels/.relsPK-!`e.drs/e2oDoc.xmlPK-!6Tdrs/downrev.xmlPK  d,Q1."Flowchart: Connector 3c"@?PK!8[Content_Types].xmlAN0EH%N@%邴K@`dOdlyLhoDX3'AL:*/@X*eRp208J妾)G,R}Q)=HiҺ0BL):T뢸WQDY;d]6O&8* VCLj"󃒝 yJ.;[wIC_ :{IOA !>Ø4 p;fɑ3׶Vc.ӵn(&poPK!8! _rels/.relsj0 }qN/k؊c[F232zQLZ%R6zPT]( LJ[ۑ̱j,Z˫fLV:*f"N.]m@= 7LuP[i?T;GI4Ew=}3b9`5YCƵkρؖ9#ۄo~e?zrPK!&gdrs/e2oDoc.xmlTn0 ?/ g:E"À-=3DMRt_?JviE&E|zI+vwh*OI#̾ߟ68L fuoU-#x]d'h`NC AOZet9֡˄4R20Uq-եuly vb, g[Jw¡&L 2@wl[2Bx{?XqGG4/LP(4].[WE~݂ k4]" w>Pzz!f6J )E1 LQԶ7{@I}" UWȻn;),źLy} v\x<N,|;\IA< `_I^& -^(GVl:Jr><#R4YၖH^q8k~Ø4 p;fɑ3׶Vc.ӵn(&poPK!8! _rels/.relsj0 }qN/k؊c[F232zQLZ%R6zPT]( LJ[ۑ̱j,Z˫fLV:*f"N.]m@= 7LuP[i?T;GI4Ew=}3b9`5YCƵkρؖ9#ۄo~e?zrPK!ٰndrs/e2oDoc.xmlTMo0 t_N?:E À-v=+ DMRt~]ӰA#뛃d/|P`ZM(C춡O/l4XWDVx 6z.F7+;aX8',:%x"h=袚L΋|Ø4 p;fɑ3׶Vc.ӵn(&poPK!8! _rels/.relsj0 }qN/k؊c[F232zQLZ%R6zPT]( LJ[ۑ̱j,Z˫fLV:*f"N.]m@= 7LuP[i?T;GI4Ew=}3b9`5YCƵkρؖ9#ۄo~e?zrPK!&gdrs/e2oDoc.xmlTn0 ?/ g:E"À-=3DMRt_?JviE&E|zI+vwh*OI#̾ߟ68L fuoU-#x]d'h`NC AOZet9֡˄4R20Uq-եuly vb, g[Jw¡&L 2@wl[2Bx{?XqGG4/LP(4].[WE~݂ k4]" w>Pzz!f6J )E1 LQԶ7{@I}" UWȻn;),źLy} v\x<N,|;\IA< `_I^& -^(GVl:Jr><#R4YၖH^q8k~Ø4 p;fɑ3׶Vc.ӵn(&poPK!8! _rels/.relsj0 }qN/k؊c[F232zQLZ%R6zPT]( LJ[ۑ̱j,Z˫fLV:*f"N.]m@= 7LuP[i?T;GI4Ew=}3b9`5YCƵkρؖ9#ۄo~e?zrPK!&gdrs/e2oDoc.xmlTn0 ?/ g:E"À-=3DMRt_?JviE&E|zI+vwh*OI#̾ߟ68L fuoU-#x]d'h`NC AOZet9֡˄4R20Uq-եuly vb, g[Jw¡&L 2@wl[2Bx{?XqGG4/LP(4].[WE~݂ k4]" w>Pzz!f6J )E1 LQԶ7{@I}" UWȻn;),źLy} v\x<N,|;\IA< `_I^& -^(GVl:Jr><#R4YၖH^q8k~ARoot Entry F0]yC1Table 0DWordDocument.SummaryInformation(/DocumentSummaryInformation87CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q