This government document is issued by Department of Budget and Management for use in Maryland
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https://www.google.com/url?client=internal-element-cse&cx=007821330218074952993:dn8mj_3oupc&q=http://dbm.maryland.gov/benefits/Documents/CY17_Decline_Form_Interactive.pdf&sa=U&ved=2ahUKEwj9pbP4uJfxAhWJy6QKHTWxD6I4PBAWMAZ6BAgFEAE&usg=AOvVaw1MsbhfaiYDugQYqGyv26_c