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<br />PLEASE lYPE ClR CLEARLY PRINT AND SUBMIT THE ORIGINAL OF THIS FORM TO THE ADDRESS OR FAX NUMBER AT THE BOTTOM OF THE PAGE. <br />DEPARTMENT tiAME <br /> <br />TEXAS EMERGENCY SERVICES RmREMENT SYSTEM <br />FORM 200-A: LOCAL BOARD AUTHORIZATION FORM <br /> <br />La f>&J~k <br /> <br />THE FOLLowr J'lolG INDMDUALS HAVE AUTHORITY TO ACCESS AND MODIFY PENSION INFORMATION AND TO COMPLETE REQUIRED <br />-ON-LINE REPO RTING ON BEHALF OF THE LOCAL BOARD OF TRUSTEES. <br /> <br /> <br />MAILING ADDRESS <br />CITY sT ZIP CO()E <br /> <br />ORGANIZATION <br />NAME <br /> <br />MAILING ADDRESS <br />CITY sT ZIP CODE <br /> <br />MAILING ADDRESS <br />CITY sT ZIP CODE <br /> <br />PHONE NO <br /> <br />~ ~~r~~&Gov <br />U/-f70-bl "2- <br /> <br /> <br />FAX NO. <br /> <br />MAILING ADDRESS <br />CITY sT ZIP CODE <br /> <br />Secretary <br /> <br />/ 1-11-'08' <br />I/?)/ ,;WJ7 <br />} 2 L uf' <br /> <br />Vice-Chair <br /> <br />OFFICE OF THE FIRE FIGHTERS' PENSION COMMISSIONER <br />TEXAS EMERGENCY SERVICES RETIREMENT SYSTEM <br />P.O. BOX 12577 AUSTIN TEXAS 78711-2577 (800)919-3372 FAX (512) 475-2430 <br />htto:/ /\^lWW.ffoc.state.t:x.us email to:info(Qlffoc.state.t:x.us <br />Form FFPC-200-A Revised 12/2005 <br />