About-to-be-retired employee requests eligibility verification for survivor's benefits.
For the best experience in completing this form use a non-mobile
1. Read the requirements for this form on page 2 of the form.
2. In Part A, enter your:
3. In Part C, choose option A or B
4. Do NOT sign this form unless in front of a notary public
5. Send or bring this form to Human Resources:
120 Crofts Hall
Form Type: Downloadable, PDF document
Requirements: Adobe Reader
Updated: March 2007
Owner: Human Resources