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Get Before Completing This Request Form, It Is Important For You To Read The Policy Statement On

Including the definition of a dependent child (if applicable). Complete the information below and forward this form in its entirety to Human Resources (CMB 1064). All new applications for marital or domestic partner benefits also require the completion of the Affidavit of Marriage or Domestic Partnership Form (http://www.pugetsound.edu/files/resources/4027 Marriage or Domestic Partner Affidavit 20090917.pdf). SSN: Name of Student: Name of Faculty/Staff Member: Faculty/Staff Member Dependent.

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