"Affidavit for Dependent Eligibility" - Maryland

Affidavit for Dependent Eligibility is a legal document that was released by the Maryland Department of Budget and Management - a government authority operating within Maryland.

Form Details:

  • Released on October 1, 2013;
  • The latest edition currently provided by the Maryland Department of Budget and Management;
  • 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 Maryland Department of Budget and Management.

ADVERTISEMENT
ADVERTISEMENT

Download "Affidavit for Dependent Eligibility" - Maryland

Download PDF

Fill PDF online

Rate (4.3 / 5) 32 votes
Page 1 of 3
10/1/2013
Affidavit for Dependent Eligibility
Name of Employee/Retiree: _________________________________________________
Employee/Retiree SSN: _____________________________
Name of Dependent: ____________________________________
Dependent Date of Birth: __________________________
Dependent SSN: _____________________________
Dependent Relationship (please check the applicable box):
CHILD
SPOUSE
Biological child
Legally married spouse
Adopted child or child placed with me for adoption
Stepchild
Grandchild*
Legal Ward, Testamentary, or Court Appointed
Guardianship*
Other Dependent Child Relative*
* These dependents must be eligible to be your tax dependent in order to be enrolled.
I solemnly affirm under the penalties of perjury under applicable state laws that the foregoing is true and accurate. I understand
that willful falsification of information contained in this Affidavit can result in referral of the matter for investigation and
prosecution, the termination of enrollment and coverage of the person identified as my dependent, and the termination of
coverage for myself (the employee/retiree). I understand that a civil action may be brought against me for any losses, including
reasonable attorney fees because of a false statement contained in this Affidavit. In addition, where permissible, employment
related action may be taken against an active employee.
I further agree that if this dependent’s status changes, I will notify my Agency Benefit Coordinator or the Employee Benefits
Division immediately to remove this dependent from my coverage. I also agree to provide the required documentation as
outlined on the Documentation Checklist which substantiates the information above.
Employee/Retiree Signature: _____________________________________
Date: __________________________
Page 1 of 3
10/1/2013
Affidavit for Dependent Eligibility
Name of Employee/Retiree: _________________________________________________
Employee/Retiree SSN: _____________________________
Name of Dependent: ____________________________________
Dependent Date of Birth: __________________________
Dependent SSN: _____________________________
Dependent Relationship (please check the applicable box):
CHILD
SPOUSE
Biological child
Legally married spouse
Adopted child or child placed with me for adoption
Stepchild
Grandchild*
Legal Ward, Testamentary, or Court Appointed
Guardianship*
Other Dependent Child Relative*
* These dependents must be eligible to be your tax dependent in order to be enrolled.
I solemnly affirm under the penalties of perjury under applicable state laws that the foregoing is true and accurate. I understand
that willful falsification of information contained in this Affidavit can result in referral of the matter for investigation and
prosecution, the termination of enrollment and coverage of the person identified as my dependent, and the termination of
coverage for myself (the employee/retiree). I understand that a civil action may be brought against me for any losses, including
reasonable attorney fees because of a false statement contained in this Affidavit. In addition, where permissible, employment
related action may be taken against an active employee.
I further agree that if this dependent’s status changes, I will notify my Agency Benefit Coordinator or the Employee Benefits
Division immediately to remove this dependent from my coverage. I also agree to provide the required documentation as
outlined on the Documentation Checklist which substantiates the information above.
Employee/Retiree Signature: _____________________________________
Date: __________________________
Determining Eligible Dependent’s Tax Status
Page 2 of 3
10/1/2013
Employee/Retiree Name: ______________________________________
Dependent Name: ____________________________________________
Things to consider regarding dependent tax status:
Employer-provided health care coverage for employees, spouses and certain other eligible dependents is exempt from federal
income and employment taxes, and in most states, state taxes. However, eligible dependents must meet various criteria for these
tax advantages to apply. If eligible for tax favored treatment, payroll deductions for benefits are taken on a pre-tax basis (deducted
from pay before taxes are assessed and withheld).
Retiree health benefit coverage is always paid on a post-tax basis, whether deducted from pension earnings or paid by the retiree
via coupon.
When coverage is provided for dependents that are not eligible for pre-tax coverage, the employee contribution for that
dependent’s coverage must be made on a post-tax basis. In addition, the employer subsidy for that coverage becomes taxable
income (imputed income) for the employee. The Benefits Guide describes imputed income in more detail.
INSTRUCTIONS:
1. Read each statement and place a check mark in the boxes that are true statements regarding this dependent.
2. You only need to satisfy one test.
3. Once you satisfy one test, you are done with this form.
4. If you cannot check ALL of the boxes under a test, then move to the next test.
5. Premiums for your dependent can be taken on a pre-tax basis if s/he meets all requirements of one test.
6. If your dependent cannot satisfy all items under any one single test, they are not eligible to be enrolled on the State Plan.
Test 1 Spouse
Your legally married spouse
Test 2 – Child
Under age 26, AND
Your child by birth or adoption; or
Your stepchild.
Test 3 – Child dependent who doesn’t satisfy Test 2
This person is any one of the following:
a. Your child by birth or adoption or your stepchild.
b. A descendant of someone in A.
This person lives with you for more than half the year.
You provide more than half of this person’s support during the calendar year.
This person is one of the following:
a. Age 26 or younger.
b. Totally and permanently disabled at any time during the calendar year (regardless of age).
This person is younger than you (unless totally and permanently disabled).
This person is unmarried (or has not filed a joint return with a spouse for the year, except to claim a refund).
Test 4 – Child dependent or other person not satisfying Test 2, 3, or 4
This person is any one of the following:
a. Your relative, under the age of 26.
b. Unrelated to you but lives with you for the entire calendar year as a member of your household and the relationship
isn’t in violation of local law.
c. Totally and permanently disabled at any time during the calendar year (regardless of age).
You provide more than half of this person’s support during the calendar year.
This person is either one of the two below:
a. Cannot be claimed as any other taxpayer’s qualifying child dependent.
b. Can be claimed as another taxpayer’s qualifying child dependent, but that taxpayer isn’t required to file a federal tax
return and doesn’t do so (or only files to get a refund of previously withheld income taxes).
Page 3 of 3
10/1/2013
DEPENDENT DOCUMENTATION CHECKLIST:
INSTRUCTIONS: You must supply documentation supporting your relationship (or your spouse’s
relationship) to your dependent. Review the checklist below for the type (relationship) of dependent
you are adding and supply ALL indicated documents with your enrollment.
For ALL dependents
Affidavit for Dependent Eligibility Form
Determining Eligible Dependent’s Tax Status Form
AND THE DOCUMENTS NOTED BELOW, BASED UPON THE DEPENDENT’S RELATIONSHIP
Legally married, opposite sex spouse or same sex spouse
Copy of Official State marriage certificate (must be a certified copy and dated by the appropriate
State or County official such as the Clerk of the Court).
Biological child of employee/retiree
Copy of the child's official state birth certificate documenting lineage**
Newborns only: a copy of the crib card or hospital discharge papers if birth certificate is not yet
available
Adopted child or child placed with you for adoption
Completed adoptions: Copy of adoption papers signed by a judge
Pending adoptions: Notice of placement for adoption from adoption agency, or copy of court
order placing child pending final adoption
Copy of child's official state birth certificate (if available)
Stepchild
Copy of the child's official state birth certificate documenting lineage**
Copy of official state marriage certificate for employee/retiree and spouse
Grandchild
Copy of child's official state birth certificate documenting lineage**
Copy of child's parent's official state birth certificate documenting lineage**
Proof of permanent residency*
Legal Ward, Testamentary, or Court appointed Guardianship (not temporary for less than 12 months)
Copy of child's official state birth certificate
Copy of court documents signed by a judge
Proof of permanent residency*
Step-Grandchild or other dependent child relative
Copy of child's official state birth certificate
Proof of relation (marriage certificates, birth certificates of any/all related parties)
Proof of permanent residency*
Child with a physical or mental incapacity that occurred prior to reaching age 26
Disability certification form (in addition to documentation listed above depending on
relationship)
* Proof of permanent residency is proof that the dependent lives at the same residence as the employee/retiree. This can be a doctor’s bill or
letter from doctor’s office on letterhead, a daycare invoice, school documents showing address or a tax document showing the child as a
dependent. An EOB from our health plan is not sufficient proof.
** Documenting lineage means to tie the dependent back to the employee/retiree through birth or marriage certificates.
Page of 3