disabled dependent certification form pdf
RI30-010: Disabled Dependent Questionnaire
Purpose: OPM is requesting this information in order to determine whether the disabled dependent is eligible for continued benefits. Routine Uses: The
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CalPERS DISABLED DEPENDENT BENEFIT
PART B: Please provide the following information about the dependent who is seeking initial or continued enrollment or recertification in the health plan
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f2441--2017.pdf
If married filing jointly, enter your spouses earned income (if you or your spouse was a student or was disabled, see the instructions for line 5). If
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