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[null,"Member Name:",{"$nulls":7},"SSN:"]
[null,"Completed by:"]
[]
[null,"Jan","Feb","Mar","Apr","May","Jun","Jul","Aug","Sept","Oct","Nov","Dec"]
[1977,{"$nulls":12},0]
[1978,{"$nulls":12},0]
[1979,{"$nulls":12},0]
[1980,{"$nulls":12},0]
[1981,{"$nulls":12},0]
[1982,{"$nulls":12},0]
[1983,{"$nulls":12},0]
[1984,{"$nulls":12},0]
[1985,{"$nulls":12},0]
[1986,{"$nulls":12},0]
[1987,{"$nulls":12},0]
[1988,{"$nulls":12},0]
[1989,{"$nulls":12},0]
[1990,{"$nulls":12},0]
[1991,{"$nulls":12},0]
[1992,{"$nulls":12},0]
[1993,{"$nulls":12},0]
[1994,{"$nulls":12},0]
[1995,{"$nulls":12},0]
[1996,{"$nulls":12},0]
[1997,{"$nulls":12},0]
[1998,{"$nulls":12},0]
[1999,{"$nulls":12},0]
[2000,{"$nulls":12},0]
[2001,{"$nulls":12},0]
[2002,{"$nulls":12},0]
[2003,{"$nulls":12},0]
[2004,{"$nulls":12},0]
[2005,{"$nulls":12},0]
[2006,{"$nulls":12},0]
[2007,{"$nulls":12},0]
[2008,{"$nulls":12},0]
[2009,{"$nulls":12},0]
[2010,{"$nulls":12},0]
[2011,{"$nulls":12},0]
[2012,{"$nulls":12},0]
[2013,{"$nulls":12},0]
[2014,{"$nulls":12},0]
[2015,{"$nulls":12},0]
[2016,{"$nulls":12},0]
[{"$nulls":11},"Total Months:",null,0]
[null,"* Legislative action may result in increased premiums in some instances.",{"$nulls":9},"Total Months:",null,0]
[{"$nulls":11},"Total Years*:",null,0]
[null,null,"Participation",{"$nulls":3},"Cross-reference SSN:"]
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[null,"38% (10 but fewer than 15)",{"$nulls":4},"Participation Code Entered:",{"$nulls":3},"Y","N"]
[null,"56% (15 but fewer than 20)",{"$nulls":4},"Validated By:"]
[null,"75% (20 or more years)",{"$nulls":4},"Validation Date:"]
[]
[null,null,"Participation exceptions:"]

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[1972,{"$nulls":12},0]
[1973,{"$nulls":12},0]
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[1983,{"$nulls":12},0]
[1984,{"$nulls":12},0]
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[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":13},0]
[{"$nulls":11},"Total Months:",null,0]
[{"$nulls":11},"Total Years:",null,0]
[null,"Grandfathered * (75%):"]
[{"$nulls":7},"Cross-reference SSN:"]
[null,"19% (10 or fewer years):"]
[{"$nulls":7},"Surviving Spouse:",null,null,"YES","NO"]
[null,"38% (>10 but <15 years):"]
[{"$nulls":7},"Validated by:"]
[null,"56% (15 but <20 years):"]
[{"$nulls":7},"Validation Date:"]
[null,"75% (20+ years):"]
[]
[]
[null,null,"* \"Grandfathered\" status means that coverage was in effect prior to January 1, 2002,  "]
[null,null,"with no subsequent break or that a covered employee retired prior to January 1, 2002."]

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