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Williams College Medical Expense Reimbursement Account (MERA)
 

Summary: Williams College
Medical Expense Reimbursement Account (MERA)
Change in Family Status Form
Please print clearly.
Name: ________________________________________________________________________
Employee ID #: _99______________________________________________________________
Date of the change in family status: _________/_________/_________
Describe the change in family status:_________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Describe your medical expense needs after the change in family status: _____________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Because of this change in family status (check one):
______ I wish to stop contributions to my MERA account.
______ I wish to establish a MERA account. (see * below)
______ I wish to change the amount currently being put into my MERA account. (see * below)
* You must also complete a new Enrollment Form and submit it with this form.

  

Source: Aalberts, Daniel P. - Department of Physics, Williams College

 

Collections: Physics