Stanislaus County DSA

Upcoming Events

Oct

Wed

E-Board Meeting
Oct 11, 2023
Big Sky Conference Room

Nov

Wed

General Membership Meeting
Nov 08, 2023
Big Sky Conference Room

Dec

Wed

E-Board Meeting
Dec 13, 2023
Big Sky Conference Room

Jan

Wed

General Membership Meeting
Jan 10, 2024
Big Sky Conference Room

Feb

Wed

E-Board Meeting
Feb 14, 2024
Big Sky Conference Room

Central Valley Retiree Medical Trust Participant Data Form

Plan Participant Name: *

Address: *

Phone: *

Date of Birth: *

Social Security Number: *

E-mail Address: *

Employee Number: *

Participating Employer / Bargaining Unit:

Stanislaus County Sheriff's Department / BU-7

Date of Hire:

Date of Termination (if applicable):

Spouse Name:

Spouse SSN:

Spouse Date of Birth:

Date of Marriage:

Dependent Information:

Name: *

Relationship: *

SSN: *

Date of Birth: *

Name:

Relationship:

SSN:

Date of Birth:

Name:

Relationship:

SSN:

Date of Birth:

I certify under penalty of perjury that the foregoing is true and correct. I understand that the Trust may pursue legal and equitable remedies and/or recoupment of benefits against me for any false, fraudulent or misleading information provided now or in other communications with the Trust Office.

Participant’s Signature: *

Use your mouse, finger, or touch device to write your signature.

Date: *