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Benefit Replacement Pay (BRP) Leveling Election Form 2 (Sample)

Forward To: Agency Payroll Office
Return By: Dec. ___, 20XX
Effective: December pay to be received Jan. X, 20XX, plus all other payments in 20XX
Employee Name: ____________________________________________

___ I DO request BRP leveling.

___ I DO NOT request BRP leveling.

Signature: ____________________________________________
Date: ____________________________________________

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