Form 2773 - Notice To Terminate A Met Full Benefits Plan Contract - 2005
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Contract Number(s)
Michigan Department of Treasury
2773 (Rev. 3-05)
Notice to Terminate a MET Full Benefits Plan Contract
Issued under Public Act 316 of 1986.
Use this notice when attending a Michigan independent or out-of-state institution OR to receive a refund. Submit this
notice to MET by July 15 before the Academic Year in which you, the Beneficiary, wish to terminate the Contract.
*Beneficiary Name (Student)
Beneficiary's Social Security Number
Street Address
Daytime Telephone
(
)
City, State, ZIP Code
Name of Institution Beneficiary Will Attend
Semester and Year to Begin Using Refund (required info.
under all options)
The beneficiary requests termination of the above referenced contract for the following reason:
_____
a.
Beneficiary will attend a Michigan Independent, Degree-granting College or University. Attach 1)
Acceptance letter, 2) W-9 form for beneficiary and 3) W-9 form for refund designee (regardless of where
you direct refund). To whom should refund be paid?
____ College ____ Refund Designee (Person in Item 16 of Contract Signature Page)
_____
b.
Beneficiary will attend an Out-of-State Institution of Higher Education. Attach 1) Acceptance letter, 2) W-9
form for beneficiary and 3) W-9 form for refund designee (regardless of where you direct refund). To
whom should refund be paid?
____ College ____ Refund Designee (Person in Item 16 of Contract Signature Page)
_____
c.
Beneficiary has received a full tuition scholarship. Attach 1) Verification of scholarship that states terms
(what costs will be covered per term/semester as well as number of terms/semesters covered or terms of
renewal), and 2) W-9 form for refund designee.
_____
d.
Beneficiary does not plan to attend a Higher Education Institution. Complete the affidavit on the reverse
side of this form stating that you, the Beneficiary, do not plan to attend a Higher Education Institution. The
affidavit must be notarized. Attach W-9 form for refund designee (Person in item 16 of Contract Signature
Page).
_____
e.
Beneficiary is Disabled or has died. (This request can be made at any time.) Attach a sworn or attested
statement of the Beneficiary's Disability. If the Beneficiary died, the person with legal authority to act on
behalf of the Beneficiary should submit a certificate of death and sign the form below in place of the
Beneficiary's signature. A W-9 form must be submitted for the refund designee in either case.
_____
f.
Beneficiary will attend a Community College and intends to terminate the Contract rather than receive
educational benefits. Refund must be provided to the Community College. Attach W-9 form for refund
designee.
_____
g.
Military. Attach 1) Copy of enlistment contract and 2) W-9 form for refund designee.
If you are unsure of the appropriate reason for termination, call MET at (800)-638-4543.
*Signature of Beneficiary (Student)
Date
*Beneficiary must be at least 18 years of age or have a high school diploma. If you are not 18 years of age, attach a copy of
your high school diploma.
MAIL TO:
Michigan Education Trust, P.O. Box 30198
Lansing, Michigan 48909
Fax: (517) 373-6967
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