Form ADM-4729 "Affidavit of Student Status" - Ohio

What Is Form ADM-4729?

This is a legal form that was released by the Ohio Department of Administrative Services - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2013;
  • The latest edition provided by the Ohio Department of Administrative Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form ADM-4729 by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

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Download Form ADM-4729 "Affidavit of Student Status" - Ohio

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STATE OF OHIO
Affidavit of Student Status
Agency Name:
Dependent Date of Birth:
I,
, after first being duly cautioned and sworn, state that:
(Name of Enrolled Employee)
My unmarried dependent
is 19-22 years of age, and attends
(Name of Dependent)
.
(Name of Accredited School)
I have attached:
A letter from the registrar with dependent’s name, school name, school phone number and statement of
dependent’s current term enrollment.
OR
An official transcript with dependent’s name, school name and semesters/quarters enrolled that include the current
term.
OR
A “Current Enrollment Verification Certificate” from the National Student Clearinghouse with dependent’s name,
school name and semesters/quarters enrolled that include the current term. ( http://www.studentclearinghouse.org/)
If the birthday occurs during a standard school break, (e.g. summer), the attached document of choice must
show enrollment in the previous term.
This section must be completed
I understand that knowingly providing false or misleading information in this Affidavit may result in any or all of the
following actions by the State of Ohio: 1) loss of coverage; 2) disciplinary action, up to and including removal; 3)
collection action to recoup payments of benefits and claims paid for individuals determined to be ineligible
dependents; and/or 4) civil and/or criminal prosecution.
I also understand that I may be required to supply copies of documentation such as certified birth certificate(s),
front/last page of income tax returns and other related documentation.
I understand it is my responsibility to notify my employer when an enrolled dependent is no longer eligible for
coverage due to age or school enrollment.
___________________________________
_______________________________
Signature of Enrolled Employee
State of Ohio User ID
Sworn to before me and subscribed to in my presence this _______ day of __________, ______
______________________________________________
Notary Public
My commission expires __________, ______.
ADM 4729 (rev. Aug. 2013)
Service, Support, Solutions for Ohio Government
STATE OF OHIO
Affidavit of Student Status
Agency Name:
Dependent Date of Birth:
I,
, after first being duly cautioned and sworn, state that:
(Name of Enrolled Employee)
My unmarried dependent
is 19-22 years of age, and attends
(Name of Dependent)
.
(Name of Accredited School)
I have attached:
A letter from the registrar with dependent’s name, school name, school phone number and statement of
dependent’s current term enrollment.
OR
An official transcript with dependent’s name, school name and semesters/quarters enrolled that include the current
term.
OR
A “Current Enrollment Verification Certificate” from the National Student Clearinghouse with dependent’s name,
school name and semesters/quarters enrolled that include the current term. ( http://www.studentclearinghouse.org/)
If the birthday occurs during a standard school break, (e.g. summer), the attached document of choice must
show enrollment in the previous term.
This section must be completed
I understand that knowingly providing false or misleading information in this Affidavit may result in any or all of the
following actions by the State of Ohio: 1) loss of coverage; 2) disciplinary action, up to and including removal; 3)
collection action to recoup payments of benefits and claims paid for individuals determined to be ineligible
dependents; and/or 4) civil and/or criminal prosecution.
I also understand that I may be required to supply copies of documentation such as certified birth certificate(s),
front/last page of income tax returns and other related documentation.
I understand it is my responsibility to notify my employer when an enrolled dependent is no longer eligible for
coverage due to age or school enrollment.
___________________________________
_______________________________
Signature of Enrolled Employee
State of Ohio User ID
Sworn to before me and subscribed to in my presence this _______ day of __________, ______
______________________________________________
Notary Public
My commission expires __________, ______.
ADM 4729 (rev. Aug. 2013)
Service, Support, Solutions for Ohio Government