If you are blind or seriously visually impaired and need this application in an alternative. No information is available for this page.If you are married and recertifying just for Supplemental Nutrition Assistance Program benefits, only one spouse must sign and date the recertification form. Counsel shall provide the neutral with the Order of Reference and Assignment Form. 1. Notify Us. Complete our Beneficiary Statement form and have the beneficiary sign it. Download our most commonly requested forms. Notice: You are required to attach to this form the following documents: A current and representative paycheck stub;. Use this form if you receive a surprise bill for health care services and want the services to be treated as in network. In completing this form employees will be acknowledging in writing that their second job is subordinate to their employment with Nassau County.