SERGEANTS BENEVOLENT ASSOCIATION 35 Worth Street New York, NY 10013 (phone) 2124316555 (fax) 2124316487 (email) healthandwelfare sbanyc.org DEPENDENT STUDENT CERTIFICATION FORM Section One: To Be.

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How to fill out the NY SBA Dependent Student Certification Form online

Filling out the NY SBA Dependent Student Certification Form accurately is essential for ensuring eligibility for health and welfare benefits. This guide will take you through the process step-by-step, providing clear instructions for each section of the form.

Follow the steps to successfully complete the form online.

  1. Click ‘Get Form’ button to obtain the form and open it in the editor.
  2. Begin with Section One, where you will provide Member Information, including Tax ID number, name, address, and email. Ensure all details are current and accurate.
  3. Enter the dependent's information with their name and date of birth. This ensures clarity about who the certification is for.
  4. Confirm the dependent's eligibility by responding to the questions regarding age, marital status, and student enrollment status. Indicate 'Yes' or 'No' accordingly.
  5. Specify the semester in which the dependent is enrolled by circling either Fall or Spring, then enter the corresponding year.
  6. Complete the Member’s signature and date fields to certify the information provided is true.
  7. In Section Two, ensure an authorized person from the registrar's office fills out the required information regarding the dependent's enrollment status and the institution's accreditation.
  8. Once all sections are filled, review the form for accuracy. You can then save, download, print, or share the completed form as needed.

Complete your NY SBA Dependent Student Certification Form online today.

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