Toll Free: 800-381-5111 Local: 517-284-4400 www.michigan.gov/ors Fax: 517-284-4416January 2nd, 2019
FiledJanuary 2nd, 2019For Public School Employees MEMBER’S NAME (LAST, FIRST, M.I.) MEMBER ID OR SSN MAILING ADDRESS DAYTIME PHONE NUMBER ( ) CITY, STATE, ZIP CODE TDP AGREEMENT #: PAYROLL DEDUCTION AMOUNT EMAIL ADDRESS