"Statement of Support" - Delaware

Statement of Support 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;
  • Easy to customize;
  • 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 "Statement of Support" - Delaware

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S
D
TATE OF
ELAWARE
Department of Human Resources
Statewide Benefits Office
STATEMENT OF SUPPORT
Employee/Pensioner Name: __________________________ Employee/Pensioner ID#:_____________
Dependent Name: __________________________________ Date: _____________________________
TOTAL COST
AMOUNT PAID BY
AMOUNT PAID BY
AMOUNT PAID BY
TYPE OF EXPENSE
OF SUPPORT
DEPENDENT
MOTHER
FATHER
Lodging Furnished
$
$
$
$
Food**
Medical & Dental Care
Transportation
Clothing
Contributions
Entertainment & Recreation
Tuition (Room & Board, etc.)
Other: (list)
TOTALS
$
$
$
$
1. Is anyone else (e.g., former spouse or natural parent) providing support on behalf of this
child?
Yes
No
a. Name of person providing support: ___________________________________________
b. Relationship: ____________________________________
c. Amount of support provided per month: ______________
d. By Court Order?
Yes
No
2. Does this person provide coverage for:
a. Health
Yes
No
Insurance Provider’s Name: ____________________
Policyholder’s I.D. #: _________________________
b. Prescription
Yes
No
Insurance Provider’s Name: ____________________
Policyholder’s I.D. #: _________________________
c. Dental
Yes
No
Insurance Provider’s Name: ____________________
Policyholder’s I.D. #: _________________________
d. Vision
Yes
No
Insurance Provider’s Name: ____________________
Policyholder’s I.D. #: _________________________
S
D
TATE OF
ELAWARE
Department of Human Resources
Statewide Benefits Office
STATEMENT OF SUPPORT
Employee/Pensioner Name: __________________________ Employee/Pensioner ID#:_____________
Dependent Name: __________________________________ Date: _____________________________
TOTAL COST
AMOUNT PAID BY
AMOUNT PAID BY
AMOUNT PAID BY
TYPE OF EXPENSE
OF SUPPORT
DEPENDENT
MOTHER
FATHER
Lodging Furnished
$
$
$
$
Food**
Medical & Dental Care
Transportation
Clothing
Contributions
Entertainment & Recreation
Tuition (Room & Board, etc.)
Other: (list)
TOTALS
$
$
$
$
1. Is anyone else (e.g., former spouse or natural parent) providing support on behalf of this
child?
Yes
No
a. Name of person providing support: ___________________________________________
b. Relationship: ____________________________________
c. Amount of support provided per month: ______________
d. By Court Order?
Yes
No
2. Does this person provide coverage for:
a. Health
Yes
No
Insurance Provider’s Name: ____________________
Policyholder’s I.D. #: _________________________
b. Prescription
Yes
No
Insurance Provider’s Name: ____________________
Policyholder’s I.D. #: _________________________
c. Dental
Yes
No
Insurance Provider’s Name: ____________________
Policyholder’s I.D. #: _________________________
d. Vision
Yes
No
Insurance Provider’s Name: ____________________
Policyholder’s I.D. #: _________________________
________________________________
___________
Employee’s/Pensioner’s Signature
Date
______________________________________
_____________
Dependent’s (Residential) Street address
Date
______________________________________
_____________
Dependent’s City, State and Zip Code
Date
A statement of Support form must be completed to substantiate support of a child between the
-
ages of 19 and 24 not born to, legally adopted, or lawfully placed for adoption by an
employee/pensioner.
A Statement of Support form must be completed and accompany the Full-Time Student
-
Certification form by August 1 for Fall Semester, December 1 for Spring Semester and any time a
change in status occurs.
A Statement of Support form must have attached a copy of the documents indicating legal
-
guardianship, permanent guardianship or custody order.
A Statement of Support form, with supporting documentation must be completed for each child
-
regardless of age.
Employee/Pensioner must sign form.
-
The completed form with supporting documentation must be returned to your HR/Benefits Office
to be retained on file for auditing purposes by SBO.
Original: 7-26-11
Revised: 11-19-14
Revised: 01-25-18
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