EXEMPTION FROM OBRA DEDUCTIONS
If one of the following applies to you, please check appropriate line and sign the statement at the
bottom of the page. If no statement applies, complete OBRA participation agreement.
Individual is a student performing services for UMass Dartmouth in which the student is
enrolled and regularly attends classes.
Individual is a current member of the State Retirement System.
Individual is hired on a temporary basis in case of fire, storm, snow, earthquake, flood or
other similar emergency.
Individual is a Non-Resident Alien not subject to FICA Medicare.
“I certify, under penalty of perjury, that I,
(please print)
am exempt from any alternative retirement deductions.”
Signature
Date