2018/05'
'
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Completion'of'this'form'is'required'to'ensure'compliance'w ith'D SS'p lan'eligib ility .'
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Employee'Name:'
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Employee'ID:'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
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Name'of'Spouse:'''
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Date'of'Marriage'(m m /d d/ yyy y):''
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Select'from'the'following'for'spouse’s'CURRENT'status:'
State'of'DE'Employee'
Employing'Agency/School'District/Charter'School:''
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Employee'ID:'''
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Delaware'Transit'Corporation'Employee'
DE'Solid'Waste'Authority'Employee'
University'of'DE'Employee;'Employ e e'ID:'' ''''''''''''''''''''''''''''''''''''''''''
DE'State'Housing'Authority'Employee'
Spouse'is'CURRENTLY'working'for'an'employer'other'than'the'State'of'DE'or'one'of'the'groups'indicate d '
above.'
Current'Employer:
'
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Employee'ID'(if'applicable):''
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Is'spouse 'in 'a 'fu ll'time'bene fit'e lig ib le 'p o sitio n ?' Yes' □' No' □'
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Please'indicate'below ,'which'Sta te'o f 'D E'o r 'gro u p 'lis ted 'a b o v e'th a t'y o u r'sp o u s e'la s t'w o rk e d 'fo r'a s'a 'fu llV'
time'benefitVeligible'employee'(if'applicable):'
Employing'Agency/School'District/Charter'School:'''
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'''''''''''''''''''''''''''''''''''''''
Employee'ID'(if'applicable):'''
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State'of'DE'Pensioner'on'LongVTerm'Disability'
Pensioner'ID:'' (enter'Spouse'S SN 'if'Pen sio ne r'ID'is'no t'known)'
State'of'DE'Pensioner'
Pensioner'ID:'' (enter'Spouse'S SN 'if'Pen sio ne r'ID'is'no t'kn o wn )'
Is'spouse'currently'receiving'a'State'of'DE'pension'check?' Yes' □' No'□'
Spouse'is'no'longer'employed'by'the'State'or'any'group'indicated'above'
' '' '''Date'of'separation:'____________________'
Spouse'is'deceased'
Are'you'receiving'a'survivor’s'pension?'' Yes' □' No' □'
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2018/05'
'
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By'my'signature'below,'I'hereby'certify'the'statements'made'on'this'form' are' true.' I'understand' that' I'may' be'
required'to'provide'copies'of'my'marriage'certificate'and/or'birth'certificates'for'dependents'enrolled'in'my'DSS'
health'plan'coverage'as'required'by'my'Human'Resources'Benefits'Office.'''
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