ࡱ> ~ bjbj  hh0G 99!!!$EEEP,4E? w"F""&?(?(?(?(?(?(?$GBD*L?!!'!|s"''L?99 m?_+_+_+'p9l8 &?_+'&?_+_+:<, = p;6Ee(<??0?<F)F(=F!=$"dM$_+K%&"""L?L?*H"""?''''F""""""""" :  MONTANA UNIVERSITY SYSTEMPRIVATE  OFFICE OF THE COMMISSIONER OF HIGHER EDUCATION Benefits Department   100 N. Park Suite 320 % PO Box 203203 % Helena, Montana 59620-3203 % (406) 444-2574 % FAX (406) 444-0222 Montana University System Employee Benefits Declaration of Adult Dependent Employee Name Social Security# Employing Campus Please specify the requested information for your eligible adult dependent: Name DOB SSN Eligibility As an employee of the Montana University System who is eligible for medical insurance coverage, I certify that the above identified person meets the following criteria for an eligible adult dependent in accordance with the Plans Supplemental Plan Document pages 1-4. (Documentation demonstrating the criteria is attached): Is at least 18 years of age; Has proof of joint ownership or joint tenancy with the Subscriber for at least the most recent six (6) consecutive months; Does not meet the legal definition of spouse or the Plans definition of dependent child; Is ineligible for any other comparable group insurance coverage; Does not have a parental relationship with the Subscriber, and is not otherwise related to the Subscriber by blood or marriage; Has a financially-interdependent relationship with the Subscriber as evidenced by at least two (2) of the following conditions: Joint ownership or lease of a residence; At least two of the following: Joint bank account Joint billing statements (residential utilities or phone) Joint credit card accounts Joint loan agreements Joint car ownership Other titles or deeds that are jointly owned Mutually-granted powers of attorney or mutually-granted health care powers of attorney; Designation of each other as primary beneficiary in wills, life insurance policies, or retirement annuities. An Eligible Dependent does not include a spouse who is currently legally separated or divorced from the Subscriber and has a court order or decree stating such from a court of competent jurisdiction. Notification of Change in or Termination of Dependent Relationship I agree, that, if the dependent relationship as designated above, no longer exists, I will notify the Montana University System in a manner set forth by the employing campus within 30 days of such change. Certification I understand all of the following: The eligibility and coverage of dependent will cease at the end of the month in which any of the above-defined criteria are no longer met: Under federal and state law, benefit coverage of certain dependents described above may result in taxable income to the employee and is subject to income tax withholding and applicable payroll taxes; Coverage for eligible dependents may only be activated during open enrollment or if a qualifying change in dependent or job status occurs during the plan year; Montana University System must be given written notice within thirty (30) days of any change in circumstances attested to in this document; Falsely certifying eligibility for dependent coverage or failing to inform Montana University System of a relevant change in eligibility requirements in any respect may result in disciplinary action against the employee; The employee will be liable for all expenditures for coverage and benefits obtained because of any misrepresentation or omission in certifying eligibility for benefits or in failing to inform Montana University System of a change in eligibility criteria. I further understand and acknowledge that the Montana University System reserves the right to require copies of any or all of the above-listed documents. If I fail to provide the copies when requested, I understand that medical insurance coverage for the named dependent will be immediately terminated. I affirm that the assertions made herein are true and correct to the best of my knowledge. Employee Signature, Social Security Number Date AFFIRMATION State of ) : ss. Country of ) On this day, of , 20 , before me, a notary public, personally appeared , who made known to me to be the person who executed the within affirmation and acknowledged to me that he/she executed the same for the purposes therein stated. Signature of Notary Public (seal) Printed Name Residing at My Commission Expires:   MONTANA STATE UNIVERSITY Campuses at Billings, Bozeman, Great Falls, and Havre THE UNIVERSITY OF MONTANA Campuses at Butte, Dillon, Helena, and Missoula Dawson Community College (Glendive) Flathead Valley Community College (Kalispell) Miles Community College (Miles City)  EMBED Word.Picture.8  MUS_EB/10/08 :<LNPX 8 V X ˥r]SI?5hGWCJOJQJhp*CJOJQJh{CJOJQJheCJOJQJ)jhBCJOJQJUhmHnHujhBUhmHnHuhBCJOJQJhO5CJOJQJ\hB5CJOJQJ\hBCJOJQJ!jhBCJOJQJUhBCJOJQJjhBCJOJQJUhB5OJQJhBOJQJ%jhSvOJQJUhmHnHuR ! @ A i  Vdgd|mgd|m$a$gd|m 0**$$ 0*d*$a$gdk$ d*$a$gdk d*$gdk$ ,Xd*$a$gdk ,X*$ u*$*$ ! @ A N R c i z    I V W նն|q|f|q|q|h;|hXCJaJh;|hCJaJh;|h|mCJaJh;|hCJOJQJaJh;|h|m5>*OJQJaJh;|h|m>*CJOJQJaJh;|h|mCJOJQJaJh|mh|m5CJOJQJaJh|mh|mOJQJaJh{CJOJQJhp*CJOJQJhBCJOJQJ%i j   H I f ; | |% & F Fd^F`gd:% & F*>d^*`>gd:gd|m     9 : W b /=WXZ[_ozABUVHV%34X@߱~~h;|h|mCJOJQJaJh|mh|mOJQJaJh;|h|m5>*OJQJaJ h|mh;|h;|h;|CJaJh;|hXCJaJh;|h5CJaJh;|h|m5CJaJh;|hCJaJh;|h|mCJaJh;|h*cCJaJ/,BVHIVW$%3h^hgd_Ih^hgd|m hd^hgdk% Zd^Zgd;| % dgd;|% & F Fd^F`gd:% & F d^`gd:34WXK@Pd^`gdi,dgdi,$a$gd cgdi,dhgdi,gd|m% & Fgd|mh^hgd_I@P   ôzk[hkh|m>*CJOJQJaJhkh9sCJOJQJaJhkh;|CJOJQJaJh|mCJOJQJaJhkh cCJOJQJaJhkh c>*CJOJQJaJhkh|mCJOJQJaJhkh|m5CJOJQJaJh|mh|mOJQJaJh;|h|mCJOJQJaJh;|h|m>*CJOJQJaJ  0235678:;=>dpdh^p`gd9spdh^p`gd bgd b p^p`gdi,gdi,dhgdi,dgdi,*/0134>@AY[\]tuvwy̽tl]Yh?MhLhLCJOJQJaJjQh9sU$j9 hSvCJUVmHnHuhSvjhSvUh{hBCJOJQJh?MhBCJOJQJhBh5sjh5sUhkh-CJOJQJaJhkh c>*CJOJQJaJhkh|mCJOJQJaJ(jhkh:CJUaJmHnHu>?@A[\xypdh^p`gd9sgdpgdSv$a$"D....()()))()()00P&P8$:p9sBP/ =!"#$% DpG....()()))()() 000P&P8$:p|mBP/ =!"#$% Dpn ]k+Sv'M PNG  IHDR^gAMAPLTEٟ pHYs"~& IDATxOl%Iz0)brV)&cXEa|A`рEA\f9/1"Si7orS^}ZXLE +*a+KOD{{|@F]{_&~sϸ}3mq?lag>ͭöϸ}3q0H~.ʴR?q֢ޒ~ǰ{85h7×N.o4X rt?ڽ-~ ]#R,c_Hæa _wZ#NblU) RWWjvW/&w|ri rLRlF~y QkE' \>'72 ȸB|gNnd]rYrazN7wSĩq{ <|Nn@I;=~+#qxGYVI祔R*V_r{ҥf&U.Osg-';O]it~`#IF.j ?us \9Ɲ=Ξݴo^.>V̈07܆-/8+7j1rjR%Npst 'Z=q TsoBgganͫeӸ`ˢ=6;lq==v mv4PO٬snZ~Jm `-) 39x]MFq3n+h8c΍=ccɓeU$UβlsK{NݬWsP:­Y&gyfVnXn;hw]mh.Xn۾J?W;ptR{T?D7vrn(ya!sL1T,;9ӌ93w]r򻹅~ͿFk-6=^X0wjF0c"{q'7/qLmnelnt6Sg3s+g.Lw`K1*hF3`̍#ȹY'ٓeƜaYRrFiں^czǜ;"2`ƫᔐ2+w5Iqy0w3c'Y8,1=T$-ĬsffK;~@${+\*άYj,]KCCms~+uvu`)=qlϺIzTSK{G6^Oڌ)gmqlf;>ǟfu)^mRպ4ڷ?mx0Ȍܲd=]*=_l^+Hp|Yհ]8X a`Ɲ׆%oO7uva`ƝdX;Y {n rg;fÌ^YC 3 ٸkd5v:>7s  ٸz.ҿte^:ťjt"[:;5) R~ ľ86 =7oo}:WLĘ/cΩ0bqOnqNnI E83L8tpOnNu\9 hLeFPZjw+JrU0|g&n>͎_"HҙV8+Y +]J!8ōEসt(YsWMs_"/o& r0Y+ϫg>,)$eM67ҖTBWx!b~n+ڷM ٓt8y[G`B-n>?k2vmhj?9{| elA-rOkك]Cx]Pf&KhRNpm4,2\uV 4 80*q{+F*;ZFXsB\*QzF5ne^?'OJ[nk! hB۪ zvY4%X_U hD6DqiUjܔD#&6/۪tw]O'D 72yo:nʰXpngP4kw&`'ܕeܼE 5] k^ɸy2ưƴ3QU(ù١GK?A5}9e~$60y&]ܨNCk*w8b ]ȽdS'&쩞2wKFF W'zY҄' BP e8$7H+(x2>zaQ 0Y[(:sN9hSϿAsyON#S'qq]?p2Y3+(2?0T(`nN,iTeK95V-U ֙Z*ޔF3slge$KvyErkN.jNf&y]ה7lu0 X-n=Llmj*sQIzc2`nTI6%|LX$r8Q)iyF'?wQ^\VaBF֐;2̲ ~wҹ|m-6jÈ@j(w&#MxRO:n!APY$xo/O-|U̺Uo6۩mLޣG8Mgk 8 s9BIۛ"~)pWԷ[ib?#; H:(Ϳ4Ê?j w2k*⎪\I34V,%p"ȝӁ#nlXwS۾Bvro1 (ܨOz?C?) oqk?_wZ;nqMG3EnPۖDl<&.GlSeXVUi^6þ o VjHv&N(2p[d|frӨnjW(¡a}sg6[KKkg5DF5op&po2֫ e8]A8g6 ۡ/6'u)Q4TL`9;&7iL^drᨏDair̭p:siƍj`ny#j5OBK>DUTmykYxswF2A.qq6XLG Oc'BQkjиs2}h,y?pJƘo6TeW"nY F5XJ[ƎsyVkVOAU[ j9"kܢvN4KͷN鱶A,oUjVFP C,A܍@UzUG_n%^ P31Smk'?~#_kޞq7,˭I6'O :Oe3-mn=XV?RpadWwUeMo]aq-F0(-bO"_WڞZRT>Im'vfsfbwG͓':ʙ=&y |7ZqOS5D@)!گ>C܏&͊5.pдŒAR|P. 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