Nusrat Jahan

208B-2393 Pembina Highway

Winnipeg, MB
R3T 2H4
January 5, 2023

The coordinator,
Manitoba International Student Health Plan

Re: Application for opt out of the UMSU Health and Dental Plan for the policy year from
September 1st, 2022 through August 31st, 2023

I am hereby writing this letter to request for opt out of the UMSU Health and Dental Plan for
the policy year from September 1st, 2022 through August 31st, 2023. My student number is
7857350. My current address is 208b-2393 Pembina Highway, Winnipeg, Manitoba, R3T
2H4.

Sincerely,
Nusrat Jahan
Department of Economics
University of Manitoba

Signature: ………………………………………

Date: ……………………………………………...