Upcoming Events

Apr
12
Wed
E-Board Meeting
Apr 12, 2023
Big Sky Conference Room
May
10
Wed
General Membership Meeting
May 10, 2023
Big Sky Conference Room
Jun
14
Wed
E-Board Meeting
Jun 14, 2023
Big Sky Conference Room
Jul
12
Wed
General Membership Meeting
Jul 12, 2023
Big Sky Conference Room
Aug
09
Wed
E-Board Meeting
Aug 09, 2023
Big Sky Conference Room

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: *






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