Csea Employee Benefit Fund Proof Of Student Status Form printable pdf download

Csea Employee Benefit Fund Proof Of Student Status Form

CSEA Employee Benefit Fund

Proof of Student Status Form

Student proof is required for all dependents age 19 and over.

TO BE COMPLETED BY MEMBER (PLEASE PRINT)

Member’s Name _____________________________________________________

EBF ID# __________________________________

Student’s Name ______________________________________________________

Date of Birth _______________________________

TO BE COMPLETED BY SCHOOL REGISTRAR’S OFFICE (PLEASE PRINT)

Name of Student ______________________________________________________________________________________________

Name of College or University ____________________________________________________________________________________

Semester Being Verified _________________________________________________________________________________________

Expected Graduation Date _______________________________________________________________________________________

Student is enrolled as (please check one):

Full Time Undergraduate (12 credits or more)

Full Time Graduate (6 credits or more)

Signature ____________________________________________________________

Date _______________________________________________________________

Title ________________________________________________________________

Phone number _______________________________________________________

MAIL COMPLETED FORM TO

CSEA Employee Benefit Fund

PO Box 516

Latham, NY 12110-0516

CSEA Employee Benefit Fund

1-800-323-2732

Csea Employee Benefit Fund Proof Of Student Status Form