╨╧рб▒с>■  +■   ■   *                                                                                                                                                                                                                                                                                                                                                                                                                                                 ░(═┴А`с░┴т\p Carthage B░a└=Ьп╝=x-L;Д!8X@Н"╖┌1╚ РArial1╚ РArial1╚ РArial1╚ РArial1╨ ╝Bell MT14а РLucida Calligraphy1╚ РArial1╚$РArial14а РLucida Calligraphy1╚ ╝Arial1и ╝Bell MT1а РArial"$"#,##0_);\("$"#,##0\)!"$"#,##0_);[Red]\("$"#,##0\)""$"#,##0.00_);\("$"#,##0.00\)'""$"#,##0.00_);[Red]\("$"#,##0.00\)7*2_("$"* #,##0_);_("$"* \(#,##0\);_("$"* "-"_);_(@_).))_(* #,##0_);_(* \(#,##0\);_(* "-"_);_(@_)?,:_("$"* #,##0.00_);_("$"* \(#,##0.00\);_("$"* "-"??_);_(@_)6+1_(* #,##0.00_);_(* \(#,##0.00\);_(* "-"??_);_(@_)д"Yes";"Yes";"No"е"True";"True";"False"ж"On";"On";"Off"]з,[$м -2]\ #,##0.00_);[Red]\([$м -2]\ #,##0.00\)$и[$-409]dddd\,\ mmmm\ dd\,\ yyyyй mm/dd/yy;@рї  └ рї  Ї└ рї  Ї└ рї  Ї└ рї  Ї└ рї  Ї└ рї  Ї└ рї  Ї└ рї  Ї└ рї  Ї└ рї  Ї└ рї  Ї└ рї  Ї└ рї  Ї└ рї  Ї└ р └ р+ї  °└ р)ї  °└ р,ї  °└ р*ї  °└ рЇ Ї└ рЇ Ї└ р ї  °└ р └ р └ р0└ р0└ р └ р0└ р Q0└ р  └ р "└ р  └ р└ р(└ р"0@└ рй д └ р а └ р а@ └ УА УА УА УА УА  УА УА УА `Е"CStudent Certification formМ┴┴TН№╬ POMCOо Corporate2425 Jame Street 315-432-9171www.pomcoinc.com HeadquartersSyracuse, New York 13206315-437-9466 faxDATE:NAME:ADDRESS:CL910ID# Dependent:)FULL-TIME STUDENT CERTIFICATION AFFIDAVITCompletetion of this affidavit confirms that the above listed dependent is ninteen years or older and qualifies as a full-time student under your Health Plan. On behalf of your employer, POMCO must receive this form within 30 days of the date of this letter. If this letter is not returned to the address listed above within 30 days of the date of this letter. If this letter is not returned to the address listed above within 30 days of the date of this letter, benefits for your dependent will be terminated.l .When you enroll a dependent as a full-time student, you are stating that the dependent meets the requirements of an eligible dependent under the defined terms of your employer s health benefit plan. Full-time student eligibility is detailed in the eligibility section of your Summary Plan Description.НI confirm that the information I have provided on this Full-time Student Certification Affidavit is accurate and current. I understand that:У" I may be required, at any time, to provide documentation regarding the full-time student status of any dependent that I am covering under my employer s health benefit plan at any time. Acceptable documentation may include, but is not limited to proof of full-time student status in an accredited school of higher education, College or University, enrollment verification from registrar s office, etc.▒" I agree to immediately notify my employer of any change in my dependent s status as a full-time student should my dependent no longer meet the plan s eligibility requirements." Coverage of any dependent not meeting the criteria of a full-time student will be cancelled retroactive to the date the dependent no longer meets the plan s eligibility requirements and I will be responsible for any claims incurred on my dependent s behalf.+I further understand that this Full-time Student Certification Affidavit must be completed accurately and truthfully. I agree that if this affidavit is not truthful, I may be subject to disciplinary action up to and including termination of employment and retroactive loss of health plan coverage.Employee SignatureDate "S ╩ Г? °╦ ░(═┴А 8╤!╦*w0  d№йё╥MbP?_*+ВА% Б┴ГД&╨?'╨?(р?)р?MВ Xerox Phaser 6250DT tech offic▄дC Аъ odXXLetter    DINU"4p5^;pXORX  HцццWaterMarkHelveticaб"dXXр?р?▌c─U} ╢} m} ╢} m} $} ╢} ╢} █} } m} ╢} Т} ╢} Т} Т} $} ╢} I} ╢} ╢8  @ @ @                 ┤@┤@i@Ц@    ╛¤  ╛ ¤ ╛╛ ¤ ╛   ¤  ╛  ¤ ╛ ¤ ╛ ╛ ¤ ╛   ¤  ╛  ¤ ╛╛╛¤  ╛&$$$$$$$$$$╛╛¤  ╛& %%%%%%%%%%¤  ╛$ &&&&&&&&&&¤  ╛ &&&&&&&&&& ¤  ╛ %%%%%%¤  ╛&&&&&&¤  ╛ %%%%%%%%%¤ ╛¤ !╛,!!!!!!!!!!!!!!!!!!!╛.!!!!!!!!!!!!!!!!!!!!╛.!!!!!!!!!!!!!!!!!!!!╛.!!!!!!!!!!!!!!!!!!!!╛.!!!!!!!!!!!!!!!!!!!!╛.!!!!!!!!!!!!!!!!!!!!╛.!!!!!!!!!!!!!!!!!!!!¤ !╛,!!!!!!!!!!!!!!!!!!!╛.!!!!!!!!!!!!!!!!!!!!╛.!!!!!!!!!!!!!!!!!!!!╛.!!!!!!!!!!!!!!!!!!!!╫8вЇNКt 886,$R0>222222>22  ! # $ % & ' ( )е@*Ц@, - . 0 1 2 3 6 7 ¤ !╛, !!!!!!!!!!!!!!!!!!!╛.!!!!!!!!!!!!!!!!!!!!!¤ #!╛*#!!!!!!!!!!!!!!!!!!╛,$!!!!!!!!!!!!!!!!!!!╛,%!!!!!!!!!!!!!!!!!!!╛,&!!!!!!!!!!!!!!!!!!!╛,'!!!!!!!!!!!!!!!!!!!¤ (!╛*(!!!!!!!!!!!!!!!!!!╛,)!!!!!!!!!!!!!!!!!!!╛,*!!!!!!!!!!!!!!!!!!!¤ ,!╛*,!!!!!!!!!!!!!!!!!!╛,-!!!!!!!!!!!!!!!!!!!╛,.!!!!!!!!!!!!!!!!!!!¤ 0"╛,0"""""""""""""""""""╛.1""""""""""""""""""""╛.2""""""""""""""""""""╛.3""""""""""""""""""""╛6 ╛6 ¤ 7#╛7#####¤ 7 #╛7#####╫*ph>2<0000<00<00>2228>┤@   хЄ7777 ,.0366 66           !#'    (*я 7╕М╨╔ъy∙║╬МВкKй www.pomcoinc.comр╔ъy∙║╬МВкKй 2http://www.pomcoinc.com/gg    @ ■ рЕЯЄ∙OhлС+'│┘0╝HPdx Р Ь и┤ф Carthage  Carthage Microsoft Excel@А$▐zйl╟@+уеl╟@▄╖═йl╟■ ╒═╒Ь.УЧ+,∙оD╒═╒Ь.УЧ+,∙о0ь PXx АИРШ а ╟фCarthage Central Schoolб Student Certification form  Worksheets┤ 8@ _PID_HLINKSфAlXYhttp://www.pomcoinc.com/ ■    !■   #$%&'()■   ¤   ■                                                                                                                                                                                                                                                                                                                                                   Root Entry         └F■   Workbook            }2SummaryInformation(    DocumentSummaryInformation8            "