"Certification of Tax Dependent Status for a Civil Union Spouse/Children" - Delaware

This "Certification of Tax Dependent Status for a Civil Union Spouse/Children" is a document issued by the Delaware Department of Human Resources specifically for Delaware residents with its latest version released on September 13, 2013.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Delaware Department of Human Resources.

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Download "Certification of Tax Dependent Status for a Civil Union Spouse/Children" - Delaware

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CERTIFICATION OF TAX DEPENDENT STATUS
FOR A CIVIL UNION SPOUSE/CHILDREN
State of Delaware
This form must be completed and signed by the employee when enrolling a civil union spouse and/or the civil union spouse’s children in
the State of Delaware Group Health Insurance Program.
Employee Name: __________________________________________________________________________________
Employee ID: _________________
For a civil union spouse and children of a civil union spouse to be a dependent for health plan purposes, certain requirements in Internal
Revenue Code (“IRC”) § 152 (as modified by IRC §105(b)) must be satisfied. The civil union spouse and children of the civil union
spouse must, in general:
1.
Receive at least one half of his/her support from you;
2.
Live with you in the same principal place of abode as part of your household;
3.
Not be claimed as a “qualifying child” dependent under IRC § 152(c) by anyone else (generally, a qualifying child is a dependent
under age 19, age 24 if a full-time student, that meets certain requirements);
4.
Be a U.S. citizen, a U.S. national, or a resident of the U.S., Canada or Mexico at some time during the year in which you are
claiming him/her as a dependent; and,
5.
Not file a joint federal income tax return (other than only a claim of refund) with the individual’s spouse (applicable to children
of civil union spouse).
If you select “Is a tax-qualified dependent,” you are certifying the named person is a dependent described in IRC §152 (as modified by
IRC §105(b)).
If you select “Is not a tax-qualified dependent,” you are certifying (1) the named person is not a dependent described in IRC §152 (as
modified by IRC §105(b)) and (2) you understand federal tax law requires the fair market value of the coverage extended to the named
person to be imputed to you as income on your paycheck and must be reflected on the W-2 issued to you by the State of Delaware.
Notify your Human Resources/Benefits Office in writing immediately of any changes in the named person’s tax status and
complete this form to provide change in status.
Name
Date of Birth
Tax Dependent Status
Civil Union Spouse:
Is a tax-qualified dependent
____/____/____
Is not a tax-qualified dependent
Civil Union Spouse’s
Is a tax-qualified dependent
Children:
____/____/____
Is not a tax-qualified dependent
Is a tax-qualified dependent
Is not a tax-qualified dependent
____/____/____
Is a tax-qualified dependent
____/____/____
Is not a tax-qualified dependent
Is a tax-qualified dependent
Is not a tax-qualified dependent
____/____/____
I understand federal income tax dependent status is separate from eligibility for health benefits. A designation as an dependent
described in IRC §152 will result in the State of Delaware not reporting imputed income for the value of those benefits to the IRS
for me. As a result, I understand the brief description of a federal income tax dependent above is a general summary, and I
should contact my tax advisor before signing this form. I also understand falsely certifying to the tax-dependent status of any
person may result in adverse tax consequences and potential charges of tax fraud.
In accordance with my completion of this form, I am requesting my Human Resources/Benefits Office use the following coverage
code for enrollment of my civil union spouse and/or civil union spouse’s children for health plan purposes:
_______________ (See attached Coverage Code Explanations for complete listing of coverage codes.)
Employee’s signature: _______________________________________________________ Date: ___________________________
CU Doc #1
9-13-13
CERTIFICATION OF TAX DEPENDENT STATUS
FOR A CIVIL UNION SPOUSE/CHILDREN
State of Delaware
This form must be completed and signed by the employee when enrolling a civil union spouse and/or the civil union spouse’s children in
the State of Delaware Group Health Insurance Program.
Employee Name: __________________________________________________________________________________
Employee ID: _________________
For a civil union spouse and children of a civil union spouse to be a dependent for health plan purposes, certain requirements in Internal
Revenue Code (“IRC”) § 152 (as modified by IRC §105(b)) must be satisfied. The civil union spouse and children of the civil union
spouse must, in general:
1.
Receive at least one half of his/her support from you;
2.
Live with you in the same principal place of abode as part of your household;
3.
Not be claimed as a “qualifying child” dependent under IRC § 152(c) by anyone else (generally, a qualifying child is a dependent
under age 19, age 24 if a full-time student, that meets certain requirements);
4.
Be a U.S. citizen, a U.S. national, or a resident of the U.S., Canada or Mexico at some time during the year in which you are
claiming him/her as a dependent; and,
5.
Not file a joint federal income tax return (other than only a claim of refund) with the individual’s spouse (applicable to children
of civil union spouse).
If you select “Is a tax-qualified dependent,” you are certifying the named person is a dependent described in IRC §152 (as modified by
IRC §105(b)).
If you select “Is not a tax-qualified dependent,” you are certifying (1) the named person is not a dependent described in IRC §152 (as
modified by IRC §105(b)) and (2) you understand federal tax law requires the fair market value of the coverage extended to the named
person to be imputed to you as income on your paycheck and must be reflected on the W-2 issued to you by the State of Delaware.
Notify your Human Resources/Benefits Office in writing immediately of any changes in the named person’s tax status and
complete this form to provide change in status.
Name
Date of Birth
Tax Dependent Status
Civil Union Spouse:
Is a tax-qualified dependent
____/____/____
Is not a tax-qualified dependent
Civil Union Spouse’s
Is a tax-qualified dependent
Children:
____/____/____
Is not a tax-qualified dependent
Is a tax-qualified dependent
Is not a tax-qualified dependent
____/____/____
Is a tax-qualified dependent
____/____/____
Is not a tax-qualified dependent
Is a tax-qualified dependent
Is not a tax-qualified dependent
____/____/____
I understand federal income tax dependent status is separate from eligibility for health benefits. A designation as an dependent
described in IRC §152 will result in the State of Delaware not reporting imputed income for the value of those benefits to the IRS
for me. As a result, I understand the brief description of a federal income tax dependent above is a general summary, and I
should contact my tax advisor before signing this form. I also understand falsely certifying to the tax-dependent status of any
person may result in adverse tax consequences and potential charges of tax fraud.
In accordance with my completion of this form, I am requesting my Human Resources/Benefits Office use the following coverage
code for enrollment of my civil union spouse and/or civil union spouse’s children for health plan purposes:
_______________ (See attached Coverage Code Explanations for complete listing of coverage codes.)
Employee’s signature: _______________________________________________________ Date: ___________________________
CU Doc #1
9-13-13
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