Get the free Tobacco Affidavit Statement EPO HSA - hr iu

2019 PLAN YEARTOBACCOFREE AFFIDAVIT A Tobacco free Affidavit must be completed by the employee to receive a reduction in the 2019 medical premium contribution. The employee can also certify the nonuser

How to fill out tobacco affidavit statement epo

How to fill out tobacco affidavit statement epo

1. To fill out the tobacco affidavit statement epo, follow these steps:
2. Begin by obtaining a copy of the tobacco affidavit statement epo form. This form can usually be found on the website of the organization or institution requiring the affidavit.
3. Read through the instructions provided on the form carefully to understand the purpose and requirements of the affidavit.
4. Fill out your personal information in the designated fields, such as your name, address, and contact details. Make sure to provide accurate and up-to-date information.
5. Declare your statement regarding tobacco use. This may involve stating whether you are a tobacco user or non-user, and if applicable, the frequency and duration of your tobacco use.
6. Sign and date the affidavit in the appropriate section to certify the truthfulness and accuracy of the information provided.
7. If required, have your affidavit notarized by a licensed notary public. This usually involves signing the affidavit in the presence of the notary and providing identification.
8. Make copies of the completed and notarized affidavit for your records.
9. Submit the original affidavit to the organization or institution that requested it, following their specified submission instructions.
10. Note: It is important to double-check the requirements provided by the organization or institution, as they may have additional instructions or specific documents to be submitted along with the affidavit.

Who needs tobacco affidavit statement epo?

1. Individuals who are typically required to fill out a tobacco affidavit statement epo include:
2. - Job applicants who may be subject to tobacco use policies or workplace health programs
3. - Students applying to educational institutions that have tobacco-free campus policies
4. - Individuals seeking insurance coverage that considers tobacco use as a factor
5. - Participants in research studies or clinical trials that need to assess the impact of tobacco use
6. - Recipients or applicants of certain government benefits or services that have tobacco-related criteria
7. The specific individuals who need to fill out this affidavit will depend on the policies and requirements of the organization, institution, or program they are associated with.

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