"Statement of Support" - Delaware

This "Statement of Support" is a part of the paperwork released by the Delaware Department of Human Resources specifically for Delaware residents.

The latest fillable version of the document was released on January 25, 2018 and can be downloaded through the link below or found through the department's forms library.

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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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