Fillable 13 211attachment4 (U.S. Office of Personnel Management)

Fill Online, Printable, Fillable, Blank 13 211attachment4 (U.S. Office of Personnel Management) Form

Use Fill to complete blank online U.S. OFFICE OF PERSONNEL MANAGEMENT (GA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

13 211attachment4 (U.S. Office of Personnel Management)

On average this form takes 10 minutes to complete

The 13 211attachment4 (U.S. Office of Personnel Management) form is 4 pages long and contains:

  • 0 signatures
  • 8 check-boxes
  • 37 other fields

Country of origin: US
File type: PDF

U.S.A. forms for U.S. Office of Personnel Management

BROWSE U.S. OFFICE OF PERSONNEL MANAGEMENT (GA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
CERTIFICATION OF DEPENDENT TAX STATUS FOR PURPOSES OF COVERAGE
UNDER FEHB AND FEDVIP
The Office of Personnel Management (OPM) permits coverage under the Federal Employees Health
Benefits (FEHB) Program and the Federal Employees Dental and Vision Insurance Program (FEDVIP)
for the children of a same-sex domestic partner of a Federal employee or annuitant whom the employee
or annuitant would marry but for the fact that the law in his or her state of residence does not permit
same-sex marriage. For purposes of coverage under the FEHB and FEDVIP, and for purposes of this
document, such children are considered to be stepchildren. In order to enroll a stepchild in FEHB or
FEDVIP coverage, you must first file a Declaration of Domestic Partnership with your employing office
or retirement system. In addition, you must complete an SF 2809 form to first enroll or cover your
stepchild under an existing enrollment. Please contact your agency’s human resources office or your
retirement system for more information.
When you cover your stepchild under an FEHB or FEDVIP enrollment, the fair market value of the
stepchild's coverage, less any after-tax contributions you make toward the cost of that coverage, is
taxable income to you, UNLESS your stepchild qualifies as a dependent as defined in Internal Revenue
Code Section 152 (determined without regard to subsections (b)(1) (b)(2) and (d)(1)(B)) or a stepchild
as defined under state law who, as of the end of the taxable year, has not attained age 27, whether or not
that stepchild can be claimed as a dependent on your tax return. (See IRS guidance at
http://www.irs.gov/uac/Answers-to-Frequently-Asked-Questions-for-Registered-Domestic-Partners-and-
Individuals-in-Civil-Unions.)
(Note: there are no tax consequences for an annuitant whose stepchild is covered under FEDVIP,
because the entire premium is paid for by the annuitant with after-tax dollars.)
This additional income, referred to as imputed income, is subject to applicable Federal income and/or
employment taxes as well as state taxes. It will be reported on your annual Form W-2 or 1099-R.
Because imputed income is calculated on the fair market value of coverage provided, it will be applied
even if there is no additional monthly premium cost to you to cover your stepchild(ren) under your
FEHB or FEDVIP plan. The amount of your imputed income depends upon the plan in which you are
enrolled and the number of stepchildren covered who are not tax dependents.
(Note: Imputed income does not affect calculations for your other benefits such as life insurance or
retirement.)
If you are enrolled in premium conversion (i.e. making pre-tax employee contributions), the amount of
your premium conversion allotment will not change. However, the fair market value amount that will be
imputed to you will include that portion of your premium conversion allotment that is attributable to
coverage of your stepchild(ren) who are not your tax dependents.
Therefore, you will have imputed income and will be taxed on the amount your employing agency
or retirement system contributes to provide FEHB and/or FEDVIP coverage for each of your
If you are covering your stepchild(ren) under an FEHB or FEDVIP plan, you must complete a
Certification of Dependent Tax Status for Purposes of Coverage Under FEHB and FEDVIP
(referred to below as a "Tax Certification") when the stepchild begins coverage. (Note: this
requirement does not apply to annuitants who are enrolled in FEDVIP but not FEHB.) The Tax
Certification will remain in effect from year to year, unless you file a new Tax Certification. Note,
however, that the test for determining a stepchild's tax dependent status is an annual one, and it is up to
you to determine every year, on an ongoing basis, whether the stepchild meets the applicable test for the
entire year and to file a new Tax Certification if the stepchild's tax dependent status changes.
Failure to submit a Tax Certification will result in taxation of the stepchild's coverage.
Because the determination of whether a person is a tax dependent for FEHB and FEDVIP
purposes turns on facts solely within your knowledge, your employing agency or retirement
system cannot make this determination for you. This information is only a summary of the tax
provisions governing the tax status of a stepchild for FEHB and FEDVIP purposes, and is not
legal or tax advice. Due to the complexity of these tax rules and the potential impact of any
imputed income you may incur, you should seek advice from a competent tax professional before
certifying as to the tax status of the stepchild. You may also refer to www.irs.gov for information.
For example, a worksheet from IRS publication 501 (available
at: http://www.irs.gov/uac/Publication-501,-Exemptions,-Standard-Deduction,-and-Filing-
Information-1) can be used for determining the support tests under Internal Revenue Code
section 152.
CERTIFICATION OF DEPENDENT TAX STATUS FOR PURPOSES OF COVERAGE
UNDER FEHB AND FEDVIP
PRINTED Name
of Employee/Annuitant
Last
name
First
name M.I.
Declaration of Domestic Partnership on file? □ Y □ N
PRINTED Name
of Same-Sex Domestic Partner
Last
name
First
name M.I.
Date
Signed / /
stepchild(ren), unless you certify that they are your tax dependents for purposes of health
coverage. Additionally, if you are enrolled in premium conversion, the portion of your premium
conversion allotment attributable to coverage of your stepchild(ren) will be taxed unless you
certify that they are your tax dependents for purposes of health coverage.
✔
I hereby certify that my stepchild(ren), who is/are the child(ren) of my same-sex domestic partner
enrolled under my FEHB and/or FEDVIP plan(s), are (print full name and check appropriate
box):
PRINTED Name
of Child
Last
name
First
name M.I.
□ □ my tax dependent not my tax dependent
□ covered under FEHB □ covered under FEDVIP
PRINTED Name
of Child
Last
name
First
name M.I.
□ my tax dependent □
□ □
□ □
□
□
not my tax dependent
covered under FEHB covered under FEDVIP
PRINTED Name
of Child
Last
name
First
name M.I.
my tax dependent not my tax dependent
covered under FEHB □ covered under FEDVIP
PRINTED Name
of Child
Last
name
First
name M.I.
my tax dependent □
□ □
not my tax dependent
covered under FEHB covered under FEDVIP
* If more space is needed, please indicate on this form and attach additional pages.
I understand that in order to qualify as a tax dependent for the purposes of coverage under FEHB and
FEDVIP, my stepchild(ren) must meet requirements of the Internal Revenue Code. (Please consult with
your tax advisor, and see http://www.irs.gov/ for more information.)
I understand that I will be taxed on the fair market value of any FEHB and/or FEDVIP coverage
provided to the children of my same-sex domestic partner, less any after-tax contributions I make toward
the cost of such coverage, unless I certify that my stepchild(ren) are my dependent(s) as defined in
Internal Revenue Code Section 152 (determined without regard to subsections (b)(1) (b)(2) and
(d)(1)(B)) or stepchild(ren) as defined under state law who, as of the end of the taxable year, have not
attained age 27, whether or not the stepchild(ren) can be claimed as dependent(s) on your tax return. See
attached for plan fair market value amounts.
I certify that the above information is true to the best of my knowledge and understand that false
certification could result in legal consequences, including but not limited to tax penalties and possible
disciplinary action by my employer. I will file a new Certification of Tax Status For Purposes of
Coverage Under FEHB and FEDVIP with my agency human resources office or retirement system in
the event of a change in the tax dependent status of any individual identified above.
I understand that any change in such status may result in the retroactive application of taxes to amounts
previously paid for FEHB and/or FEDVIP coverage during the year.
I understand that until I return this form and indicate that my stepchild(ren) are tax dependents
for health care purposes, the fair market value of coverage provided to my stepchild(ren) will be
treated as additional taxable income to me.
Employee’s Signature _______________________________________
Date
Signed / /
Date
Received
/ /
(to be completed by employing office)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

13 211attachment4 (U.S. Office of Personnel Management)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 19 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document