Date of Marriage. Street: ....................................................... Date of birth: ........................................................
Date of Marriage. Country ............................................ Address .............................................................................................................................................................................................................................. Telephone No. (Business) ........................................................................... (Residential) ........................................................................................... Cellular No. .................................................................................................. E-Mail address ........................................................................................... Bond Assurance
Date of Marriage. Country ............................................ If Married in Community or if a Notarial contract was entered into in terms of Section 25 (2) of the Act No. 88/1984, spouse must sign with two witnesses. Address .............................................................................................................................................................................................................................. Telephone No. (Business) ............................................................................ (Residential) ............................................................................................ Cellular No. ................................................................................................... E-Mail address ............................................................................................ Future Address ...................................................................................................................................................................................................................... Present Bondholders .................................................................................... Bond A/C No. ............................................................................................
Date of Marriage. The parties were married on , at , and ever since then have been and are husband and wife.
Date of Marriage. E. Unmarried dependent children age nineteen or older are eligible to remain under Family Coverage if a doctor certifies that the child cannot support himself or herself because of a mental or physical impairment which occurred before he or she reached the age of nineteen. Any Member with Family Coverage may add new dependent children at any time. However, the application for coverage must be made within thirty days of acquisition of the new child. The City of Cheyenne may from time to time require verification of permanent disability of Member, of employment, of full-time student status, or of mental or physical disability. The City shall offer Members fifty years of age or older who elect to retire the option of maintaining the current health insurance policy at the single rate. The City will pay a maximum of $300.00 per month toward the single coverage. The policy will remain in effect until the Member attains the age of eligibility for medicare, or becomes eligible for coverage through another employer. Members hired after July 1, 2013 will not be eligible for this provision.
Date of Marriage. [Check and complete only one of the following options, (a) or (b).]
