Form Pebtf-7 - Student Certification Form (Page 2 of 2) in pdf

Form Pebtf-7 - Student Certification Form Page 2

STUDENT VERIFICATION FORM

(To Be Completed by the Educational Institution)

This information is being provided to the Pennsylvania Employees Benefit Trust Fund (PEBTF) who

administers health care benefits to Commonwealth of Pennsylvania employees/retirees and their

eligible dependents.

Student Name: ____________________________________________________________________________________

Student Social Security Number: ______________________________________________________________________

Current Semester Attending: ________________

Number of Credit Hours________

Full Time_____

Part Time_____

Not Enrolled_____

Withdrawal_____

Date (if applicable) ________

Graduated_____

Date (if applicable)_________

Name of Educational Institution: ______________________________________________________________________

Address of Registrar’s Office: ________________________________________________________________________

Address of Registrar’s Office:

________________________________________________________________________

Address of Registrar’s Office:

________________________________________________________________________

Address of Registrar’s Office:

Telephone Number of Registrar’s Office: _______________________________________________________________

This is authorization for the educational institution to release information to the PEBTF.

___________________________________

______________

Student Signature

Date

The information set forth herein is obtained from the student’s academic records and is an accurate

reflection of the student’s enrollment status.

_____________

___________________________________

Date

Signature of the Registrar

Educational Institution Seal

Form Pebtf-7 - Student Certification Form Page 2