Dependent Student Semester
Verification Form
Thank you for providing the information requested. Please sign below and return as
quickly as possible to insure continuation of benefits. I certify that all of my responses on
this form are accurate and correct. I understand that it is my responsibility to notify the
fund office of any changes in the above information.
Date
Spring 2022 semester credit hours:Fall 2021 semester credit hours:
The anticipated date of graduation: Name and address of college or school:
DateMember
Member Signature:
Dependent Student
Please update our files by submitting the following information. This will enable us to
expedite the processing of your claims when submitted. No dental claims will be
processed and no vision verification numbers will be given to providers until this form is
completed in its entirety and returned to the Benefit Trust office.
Dear,
For the 2021-2022 school year:
1. Is this dependent a full time student?:
Yes No
3. If your answer is “yes” to Numbers 1 and 2 above, please have the registrar of the school where the dependent attends
complete the following information and affix the school seal.
2. Is he/she primarily (more than 51%) dependent on you for support and maintenance?
Yes No
Phone: (845) 562-7988 • 52 Pierces Road Newburgh NY 12550
