"Dependent Verification Affidavit Form" - California

Dependent Verification Affidavit Form is a legal document that was released by the California Public Employees' Retirement System - a government authority operating within California.

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P.O. Box 942715 Sacramento, CA 94229-2715
CalPERS
888 CalPERS (or 888-225-7377) | Fax: (800) 959-6545
www.calpers.ca.gov
California Public Employees' Retirement System
Dependent Verification Affidavit
At least once every three years, California Government Code Section 22843.1 requires your
Employer to verify the eligibility of your dependent(s). This Affidavit is required to be completed by
the Subscriber.
Important!
Active Employees: Return this Affidavit and the required supporting documents to your agency’s
personnel office.
Retirees: Return this Affidavit and the required supporting documents to CalPERS.
SECTION A: Subscriber Information
Subscriber Name: ____________________________________________________________
Subscriber CalPERS ID/SSN: _______________________________ ___________________
SECTION B: Dependent(s) Requiring Verification
List all your dependents required to be verified.
Dependent Name
Relationship
Date of Birth
Page 1 of 5
P.O. Box 942715 Sacramento, CA 94229-2715
CalPERS
888 CalPERS (or 888-225-7377) | Fax: (800) 959-6545
www.calpers.ca.gov
California Public Employees' Retirement System
Dependent Verification Affidavit
At least once every three years, California Government Code Section 22843.1 requires your
Employer to verify the eligibility of your dependent(s). This Affidavit is required to be completed by
the Subscriber.
Important!
Active Employees: Return this Affidavit and the required supporting documents to your agency’s
personnel office.
Retirees: Return this Affidavit and the required supporting documents to CalPERS.
SECTION A: Subscriber Information
Subscriber Name: ____________________________________________________________
Subscriber CalPERS ID/SSN: _______________________________ ___________________
SECTION B: Dependent(s) Requiring Verification
List all your dependents required to be verified.
Dependent Name
Relationship
Date of Birth
Page 1 of 5
SECTION C: Required and Acceptable Verification Documents
Review the table below to assist with the required and acceptable documentation needed to verify
each dependent’s eligibility. All required documents MUST include a date, your name, and the
name of the dependent being verified.
Relationship Type
Acceptable Verification Documents
A copy of your marriage certificate AND one of the following
Spouse
documents:
A copy of the front page of the most recent federal or
state tax return confirming dependent as your spouse
OR
A copy of a document dated within the last 60 days
showing current relationship status, such as a recurring
household bill or joint statement of account. The
document must list your name, the name of your spouse,
and your address.
A copy of your Declaration of Domestic Partnership registered
Registered Domestic Partner
with the California Secretary of State AND one of the following
documents:
A copy of the front page of the most recent federal or
state tax return confirming dependent as your domestic
partner
OR
A copy of a document dated within the last 60 days
showing current relationship status, such as a recurring
household bill or joint statement of account. The
document must list your name, the name of your partner,
and your address.
Children (natural-born, adopted,
A copy of the child’s birth certificate or adoption
placement for adoption, step, or
certificate naming you, your spouse, or your domestic
registered domestic partner’s
partner as the parent of the child
children) up to age 26 (the
OR
month in which dependent
A copy of the court order naming you, your spouse, or
attains age 26)*
your domestic partner as the legal guardian of the child.
* For a stepchild, or domestic partners child, you must also
provide documentation of your current relationship to your
spouse or domestic partner as requested above.
Page 2 of 5
SECTION D: Initial and Signature of Subscriber
Every statement within this section below must be initialed by the Subscriber. The Subscriber
must sign and date.
I hereby certify under penalty of perjury:
_____ I understand the eligibility requirements described in this document and that all information
provided by me is true and correct to the best of my knowledge.
_____ I provided the required documentation to substantiate the relationship of my enrolled
dependent(s).
_____ I understand that additional information and supporting documentation may be requested
as necessary to substantiate dependent eligibility for health or dental benefits.
_____ I agree to notify CalPERS/ my employer in writing within 60 days upon the dissolution of a
marriage, domestic partnership, or when a change in a dependent’s eligibility occurs.
_____ I agree that I am responsible for ensuring that my health enrollment information for myself
and my family members is accurate. If I do not maintain accurate health enrollment
information, I may be liable for reimbursement of health premiums or health care services
incurred during the ineligibility period.
Subscriber Name:_____________________ Subscriber CalPERS ID: _______________
Subscriber Signature: _______________________________
Date: ________________
Page 3 of 5
SECTION E: Employer Authorization
For Employer Use Only
This section must be initialed, signed, and dated by the personnel office’s Human Resources
Representative.
I hereby certify that:
______ I am a duly appointed and qualified representative of the agency/department.
______ I have reviewed the employee’s supporting documents to verify each dependent‘s
eligibility.
______ I informed the employee they are required to notify their employer in writing within 60 days
upon the dissolution of a marriage or termination of domestic partnership, when a parent-
child relationship ceases, or a change in a dependent‘s eligibility occurs.
______ I informed the employee they may be required to reimburse their employer, the health,
dental, or vision benefit plan, and CalPERS for expenditures made for medical claims, or
health premiums incurred during the ineligibility period of any family member if any of the
submitted documentation is found to be inaccurate or fraudulent and that a review of
eligibility can occur at any time.
______ I retained copies of the employee’s health, dental, and vision enrollment form(s) and all
supporting documents to verify eligibility of employees’ dependent(s) in the employee’s
Official Personnel File.
______ I will provide a copy of this completed affidavit to the employee.
______ Based on the information provided and review of the documentation, I am approving the
enrollment of such dependent(s).
HR Representative Name: _________________________ Job Title:___________________
HR Representative Signature: _______________________
Date:___________________
Page 4 of 5
ivacy Notice
The privacy of personal information is of the ut most importance to Cal PERS.
The following informat ion is provided to you in compliance wit h the Informat ion
Practices Act of 1977 and the Federal Privacy Act of 1974.
lnfonna tion Purpose
The infor mation requested is collected pursuant
to the Government Code (sections 20000 et seq.)
and will be used for administration of Board
duties under the Retirement l aw. the
Social
Security Act, and the Public Employees' Medical
and Hospital Care Act, a s the case may be.
Submission of the requested information is
mandatory. Failure to comply may result in
CalPERS being unable to perform its functions
regarding your status.
Please do not include in formation that is
not requested.
Social Security Numbers
Social Security numbers a re collected on a
mandatory and voluntary basjs,
If
this is CalPERS'
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
Social Security number has already been provided,
disclosure is voluntary. Due to the use of Social
Security num bers by other agencies for
identification purposes, we may be unable to
verify eligibility for benefits w ithout the number.
AcaIPERS
Soc ial Security numbers are used for t he
following purposes:
1.
Enrollee ident ification
2. Payroll deduction/state contr ibutions
3. Billing of contracting agencies for employee/
em ployer contr ibutions
4 . Reports lo CalPERS and other slate agencies
5. Coordination of benefits am ong carr iers
6. Resolving member appeals, com plaints,
or gr ievances with health plan carr iers
Information Disclosure
Portions of this informaUon may be tr ansferred
to other state agencies (such as your employer) ,
physicians, and insurance carriers, but only
in str ict accordance with current statutes
regarding confidentialit y.
Your Rights
You have the r ight to review your m embership
files maintained by the System. For questions
about this notice, our Privacy Policy, or your r ights,
please wr ite to the Cal PERS Privacy Otticer at
400
Q
Street, Sacramento, CA 95811 or call us
at 888 CalPERS (or 888-225-7377) .
May
2016
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