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PAYMFHF 10NCHE3t AND ELIGIBILITY CEnIPICATICN <br />EMPLOYER <br />()tttLIPIEO BENEFICIARY (.gang and <br />Address) <br />T0: City of Mounds View FAON; <br />2401 Highway 30 <br />Hounds View, MN 55112 <br />HERE IF THIS IS A OWM Gp <br />BENEFIT gMVIGE FOR, ADDRESS <br />1. <br />2. 6. <br />3. — _ 7. <br />4. B.- <br />Attached is the monthly payment of S <br />to continue benefits for the persau dentlf red abovasent ro later than , <br />I hereby certify under penalty of perjury under the Is" of rho Stet, of <br />that this information is true and correct to the beat of W knowled further <br />certify that we of the dge an <br />listed persons has suffered a -qualifying event-, as sat <br />forth belay, and each oontlnuos to be eligible for contim.,d benefits under the <br />Plane and that I signed this document at <br />city, atate <br />Disqualifying Events: <br />Passage of 18 Months fro" termination of employment or <br />reduction <br />nnI to Medicare; <br />36 months Iran other "qualifying avant.; <br />age under another group health plan. <br />Date .Stgnatu- re �� <br />Perjury is punishable both as a criminal and A civil offense. The person <br />algning this form may be liable for any falsification. <br />Form CDBRA-3 <br />PAYMENr VOL"ER AND ELIGIBILITY CERPIFICATICH <br />EMPLOYER <br />CGALIFIED BENEFICIARY thane and <br />Address) <br />TO -'City of Hounds View <br />2401 Highway 30 <br />Mounds View, M; 55112 <br />El CNFxx HERE IF OW:GE of <br />THIS IS A <br />BENEFIT NVEWIGE FOR: ADDRESS <br />1. <br />2. — 6. <br />3. -- ---- <br />4, B. <br />Attached is the Monthly Paymont of S <br />to continue benefits for the persors ldc.,tlfied aiovexnt no later than <br />I hereby certify under penalty of Perjury urder the laws of the State of <br />that this fnf0rmatlon is true ad correct <br />nto the best of mY knowledge send further <br />certify that none of the listed persons forth telw, and each contihas suffered a -qualifying evert., as set <br />nues to be eligible for c,etlnued plan, and that I signed this document at benefits under the <br />city, stets <br />ennuimeetDisqualifying Events: Passage of 1B nonths from terminatlor, of employment or <br />reduction in hours; passage of 36 nenths from other -qualifying event.; <br />entitlement to Medicare, coverage under another group health plan. <br />W­'teStgnawrO <br />Perjury is P;nishable both as a crhmfml add a civil offense. The parson <br />signing this form my he liable for any falsification. <br />Form CDBRA-3 <br />