Questions If you have any questions, please contact your Personnel Specialist. /s/ MARIA J. LOPEZ, Manager Personnel Operations Attachments MJL/KS ATTACHMENT A State of Department of Personnel Administration – RETIREE VISION PLAN DEDUCTION AND ENROLLMENT AUTHORIZATION DPA Form 695 (New 02-2007) Please type or use ballpoint pen, print clearly send completed forms to vision plan vendor. – See General Terms of Enrollment and Privacy Statement on back. Section A - Retiree Information (if Section B Dependent Information – no dependents, skip Section B and go to Section C) Section C Enrollment Election –
Questions If you have any questions, please contact your Personnel Specialist. /s/ MARIA J. LOPEZ, Manager Personnel Operations Attachments MJL/KS ATTACHMENT A State of – Department of Personnel Administration RETIREE VISION PLAN DEDUCTION AND ENROLLMENT AUTHORIZATION DPA Form 695 (New 02-2007) Please type or use ballpoint pen, print clearly – send completed forms to vision plan vendor. See General Terms of Enrollment and Privacy Statement on back. Section A - Retiree Information Section B – Dependent Information (if no dependents, skip Section B and go to Section C) Section C – Enrollment Election