Form Pebtf-7 - Student Certification Form printable pdf download

STUDENT CERTIFICATION FORM

Note: All information requested below MUST be completed.

Active

Retired

MEMBER INFORMATION (Please print or type):

1. Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

2. Name (First, M., Last): ____________________________________________________________________________________

3. Address: Street___________________________________________________________________________________________

City ___________________________________________________________ State _________ Zip Code ______________

4. Telephone number: HOME: (_____) __________________________WORK: (_____)__________________________________

5. Is child’s other parent a PEBTF member? Yes _____ No _____

If yes, please give other parent’s social security number ___ ___ ___ - ___ ___ - ___ ___ ___ ___

6. Are you responsible for more than 50% of dependent’s support? Yes _____ No _____

If no, please attach an explanation to support child dependency status.

7. Was child claimed as a dependent on your last Federal Income Tax Return? Yes _____ No _____

If no, please attach an explanation to support child dependency status.

APPLYING FOR STUDENT CERTIFICATION:

To continue coverage, this form must be completed and returned to the PEBTF within 30 days. Failure to return this form will result

in termination of your child's coverage. NOTE: Certification is required twice each year.

BE SURE TO SIGN BELOW IN THE BOXED AREA

DEPENDENT CHILD INFORMATION:

8. Dependent’s Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

9. Dependent’s Name (First, M., Last): __________________________________________________________________________

10. Dependent’s Date of Birth: Month __________ Day __________ Year __________

11. Relationship to Member:

_____Natural/Adopted Child

_____Step-Child

_____Other ______________________________

(If other please explain)

12. Dependent’s Marital Status:

Single_____

Married_____

Divorced_____

13. Is dependent employed during school year?

Yes _____ No _____

13.

If yes, is dependent eligible for health coverage through their employer?

Yes _____ No _____

14. Dependent is:

Full-time student _____

Part-time student _____

15. Name of School: _________________________________________________________________________________________

Registrar’s Address: ______________________________________ City _________________ State _______ Zip ___________

Phone number: (____)________________________

16. Type of School: High School _____ College _____ Trade _____ If other explain ______________________________________

17. If dependent is graduating within the next 12 months, show date of graduation:

MONTH __________, DAY __________, YEAR __________

MEMBER: I CERTIFY THAT THIS INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE. BY SIGN-

ING THIS CERTIFICATION, I AM AUTHORIZING THE PEBTF TO VERIFY MY CHILD’S STUDENT STATUS

WITH THE REGISTRAR’S OFFICE OF THE EDUCATIONAL FACILITY SHOWN ABOVE.

Member’s Signature:__________________________________________________________ Date Signed:________________

Student Dependent Signature: __________________________________________________ Date Signed:________________

NOTE: Eligibility for benefit coverage as a student dependent and continuance of this coverage is subject to periodic evaluation

and recertification. Should student status or information on this certification form change at any time, benefit coverage must be

reconsidered by the PEBTF.

THIS SECTION FOR PEBTF USE ONLY

Certification approved on: ___________________________________________by ________________________________________

Certification denied on: _____________________________________________by ________________________________________

a s d

PEBTF—7 (JANUARY) 12/08

Form Pebtf-7 - Student Certification Form

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