Get Tobacco Use Certification Form.pdf

Completing the Tobacco Use Certification Form online is a straightforward process designed to ensure that all applicable individuals accurately report their tobacco use status. This guide will provide you with step-by-step instructions on how to fill out each section of the form effectively.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to access the Tobacco Use Certification Form in your preferred online format.
2. Enter your name in the 'Employee/Retiree Name' field. Ensure that you provide your full legal name for accurate identification.
3. In the next field, input your Employee ID or, if you are a retiree, specify the institution from which you retired.
4. In the tobacco use certification section, check the appropriate box to indicate whether you are currently a tobacco user or not. Select one option.
5. List the names of your covered dependents who are aged 18 or older in the space provided. For each dependent, indicate whether they are a tobacco user by circling 'Yes' or 'No'.
6. Review the attestation statement carefully. By signing, you confirm that the information provided is true to the best of your knowledge and acknowledge the consequences of providing false information.
7. Sign and date the form in the designated fields to complete the certification.
8. After filling out the form, make sure to save your changes. You can then download, print, or share the completed Tobacco Use Certification Form as needed.

Complete your Tobacco Use Certification Form online today to ensure accurate reporting of your tobacco use status.