Upcoming Events

Jul
06
Wed
Emergency Membership Meeting
Jul 06, 2022
Big Sky
Jul
13
Wed
General Membership Meeting
Jul 13, 2022
Big Sky Conference Room
Aug
10
Wed
E-Board Meeting
Aug 10, 2022
REACT Center
Sep
14
Wed
General Membership Meeting
Sep 14, 2022
Big Sky Conference Room
Oct
12
Wed
E-Board Meeting
Oct 12, 2022
REACT Center

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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