"Full-Time Student Certification Form" - Delaware

Full-Time Student Certification Form is a legal document that was released by the Delaware Department of Human Resources - a government authority operating within Delaware.

Form Details:

  • Released on January 25, 2018;
  • The latest edition currently provided by the Delaware Department of Human Resources;
  • Ready to use and print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Delaware Department of Human Resources.

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Download "Full-Time Student Certification Form" - Delaware

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S
D
TATE OF
ELAWARE
Department of Human Resources
Statewide Benefits Office
FULL-TIME STUDENT CERTIFICATION FORM
Form to be completed when child is not born to, adopted by, or lawfully placed for adoption with employee/pensioner and is:
- unmarried; and
- dependent upon employee/pensioner for at least 50%
- between ages of 19 and 24; and;
support; and
- resides with employee/pensioner in a regular
- considered to be employee’s/pensioner’s dependent under
parent-child relationship; and
Section 105 of Internal Revenue Code; and
- is a full-time student in accordance with school policy.
EMPLOYEE/PENSIONER INFORMATION (To Be Completed By Employee/Pensioner)
EMPLOYEE/PENSIONER LAST NAME
EMPLOYEE/PENSIONER FIRST NAME
MI
EMPLOYEE/PENSIONER ID NUMBER
STUDENT INFORMATION (To Be Completed By Employee/Pensioner)
STUDENT LAST NAME
STUDENT FIRST NAME
MI
The student is: □ Male
□ Female
DATE OF BIRTH
STUDENT SOCIAL SECURITY NUMBER
_____/_____/______
NAME OF SCHOOL STUDENT IS ATTENDING
ADDRESS OF SCHOOL
PHONE NUMBER OF SCHOOL
(
)
-
Attach school’s policy defining Full-Time Student Status AND
Student is enrolled for:
enrollment letter, registration, or invoice to document enrollment
Number of Credit hours: ___________
as a full-time student.
EXPECTED END DATE OF FULL-TIME ATTENDANCE?
TERMS OF AGREEMENT
I certify that:
1) the statements made above are true and understand that the State of Delaware’s Department of Human
Resources reserves the right to recover from me, claim payments made to or on behalf of an ineligible
dependent;
2) Full-Time Student Certification Form shall be completed no later than August 1 for Fall Semester; December
1 for Spring Semester; and any other time the student’s enrollment status changes. The completed form must
be provided to my HR/Benefits Office who is responsible for maintaining the original copy for auditing
purposes by SBO;
3) Full-Time Student Status is defined by the school’s policy and a copy of the school’s transcript or letter on
school letterhead stating status of enrollment must be attached to this form; and
4) Statement of Support form with copy of legal guardianship, permanent guardianship or custody order has
also been completed and provided to my HR/Benefits Office to be maintained for auditing purposes by SBO.
EMPLOYEE/PENSIONER SIGNATURE
DATE
A Full-Time Student Certification Form MUST be completed for each child.
Employee/Pensioner MUST sign form.
Benefits coverage will be provided to the end of the month for which the child is eligible.
Original: 7-26-11
Revised: 11-19-14
Revised: 01-25-18
S
D
TATE OF
ELAWARE
Department of Human Resources
Statewide Benefits Office
FULL-TIME STUDENT CERTIFICATION FORM
Form to be completed when child is not born to, adopted by, or lawfully placed for adoption with employee/pensioner and is:
- unmarried; and
- dependent upon employee/pensioner for at least 50%
- between ages of 19 and 24; and;
support; and
- resides with employee/pensioner in a regular
- considered to be employee’s/pensioner’s dependent under
parent-child relationship; and
Section 105 of Internal Revenue Code; and
- is a full-time student in accordance with school policy.
EMPLOYEE/PENSIONER INFORMATION (To Be Completed By Employee/Pensioner)
EMPLOYEE/PENSIONER LAST NAME
EMPLOYEE/PENSIONER FIRST NAME
MI
EMPLOYEE/PENSIONER ID NUMBER
STUDENT INFORMATION (To Be Completed By Employee/Pensioner)
STUDENT LAST NAME
STUDENT FIRST NAME
MI
The student is: □ Male
□ Female
DATE OF BIRTH
STUDENT SOCIAL SECURITY NUMBER
_____/_____/______
NAME OF SCHOOL STUDENT IS ATTENDING
ADDRESS OF SCHOOL
PHONE NUMBER OF SCHOOL
(
)
-
Attach school’s policy defining Full-Time Student Status AND
Student is enrolled for:
enrollment letter, registration, or invoice to document enrollment
Number of Credit hours: ___________
as a full-time student.
EXPECTED END DATE OF FULL-TIME ATTENDANCE?
TERMS OF AGREEMENT
I certify that:
1) the statements made above are true and understand that the State of Delaware’s Department of Human
Resources reserves the right to recover from me, claim payments made to or on behalf of an ineligible
dependent;
2) Full-Time Student Certification Form shall be completed no later than August 1 for Fall Semester; December
1 for Spring Semester; and any other time the student’s enrollment status changes. The completed form must
be provided to my HR/Benefits Office who is responsible for maintaining the original copy for auditing
purposes by SBO;
3) Full-Time Student Status is defined by the school’s policy and a copy of the school’s transcript or letter on
school letterhead stating status of enrollment must be attached to this form; and
4) Statement of Support form with copy of legal guardianship, permanent guardianship or custody order has
also been completed and provided to my HR/Benefits Office to be maintained for auditing purposes by SBO.
EMPLOYEE/PENSIONER SIGNATURE
DATE
A Full-Time Student Certification Form MUST be completed for each child.
Employee/Pensioner MUST sign form.
Benefits coverage will be provided to the end of the month for which the child is eligible.
Original: 7-26-11
Revised: 11-19-14
Revised: 01-25-18