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Summary

Section 40.05 (4g), Wis. Stat., provides additional months of state contribution toward health insurance premiums for certain military service personnel who receive a military leave of absence or are eligible for reemployment under Wis. Stat. § 321.64.

If you would like to complete the form electronically, be sure to first download the form, complete using Acrobat Reader, and save.

Submit the completed form to your employer.

Note: ETF is unable to assist with Adobe Acrobat Reader technical or compatibility issues. If you need assistance, please visit Adobe’s help site.