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STATE HEALTH BENEFIT PLAN (SHIP) REMOVAL OF SPOUSAL SURCHARGE AFFIDAVIT Effective January 1, 2009, Policyholder/Plan Member Name Social Security Number Check appropriate box, sign and date this form.

How to fill out spousal surcharge affidavit 3

How to fill out spousal surcharge affidavit 3:

1. Start by reviewing the instructions: Before filling out the affidavit, carefully read the provided instructions. This will ensure that you understand the purpose of the form and what information is required.
2. Gather necessary information: Make sure you have all the necessary information at hand before filling out the affidavit. This may include personal details such as names, addresses, and contact information of both spouses, as well as any financial information or documentation required.
3. Understand the purpose of the affidavit: The spousal surcharge affidavit 3 is typically used to determine if a spouse is eligible for certain benefits or allowances. The form may require you to provide details about your marriage, financial situation, or any other relevant information that will help determine your eligibility.
4. Fill out personal information: Begin by filling out the personal information section of the affidavit. This may include names, dates of birth, Social Security numbers, and contact information for both spouses. Ensure the information is accurate and up to date.
5. Provide marriage details: In the affidavit, you may be required to provide details about your marriage. This may include the date and place of the marriage, as well as any previous marriages and their dissolution. Fill in this section accurately and completely.
6. Financial information: The affidavit may require you to provide information about your financial situation. This may include details about your income, assets, debts, and expenses. Fill in this section accurately, providing any necessary documentation as required.
7. Review and sign the affidavit: Once you have filled out all the necessary sections of the affidavit, carefully review the information for accuracy and completeness. Ensure that all relevant information has been provided and that all required fields have been filled. Sign and date the affidavit as indicated.

Who needs spousal surcharge affidavit 3:

1. Individuals applying for certain benefits or allowances: The spousal surcharge affidavit 3 is typically required for individuals who are applying for certain benefits or allowances, where the eligibility is determined based on marital status and financial information.
2. Spouses seeking approval or exemption: If a spouse wants to be considered for a particular program, benefit, or exemption that requires providing proof of marriage or financial information, they may need to fill out the spousal surcharge affidavit 3.
3. Employees with spousal surcharge inquiries: Some employers or organizations may require their employees to fill out the spousal surcharge affidavit 3 if they have inquiries related to benefits, allowances, or insurance programs that involve spousal eligibility.

It is important to note that the specific requirements for who needs the spousal surcharge affidavit 3 may vary depending on the organization, program, or institution requesting the form. It is recommended to consult the instructions or contact the relevant authorities for accurate information.

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What is spousal surcharge affidavit 3?

Spousal surcharge affidavit 3 is a form that must be completed by employees who wish to decline employer-provided health coverage for their spouse or partner due to a surcharge.

Who is required to file spousal surcharge affidavit 3?

Employees who wish to decline employer-provided health coverage for their spouse or partner due to a surcharge are required to file spousal surcharge affidavit 3.

How to fill out spousal surcharge affidavit 3?

Spousal surcharge affidavit 3 can be filled out by providing the required information about the spouse or partner, the reason for declining coverage, and any supporting documentation as requested.

What is the purpose of spousal surcharge affidavit 3?

The purpose of spousal surcharge affidavit 3 is to verify and document the decision of the employee to decline coverage for their spouse or partner due to a surcharge.

What information must be reported on spousal surcharge affidavit 3?

The information required on spousal surcharge affidavit 3 typically includes details about the spouse or partner, the reason for declining coverage, and any supporting documentation as requested.