Affidavit of Parent-Child Relationship Instructions
ection A: Employee/Annuitant Information
Enter your name, Social Security number, date of birth, the date you assumed the primary parental status or duties,
and your relationship to the PCR dependent.
Section B: PCR Dependent Information
Enter the PCR dependent's name, Social Security number, date of birth, and address (if different from yours).
Section C: Supporting Documentation Requirements
Select "yes" or "no" to certify that your PCR dependent is either under the age of 19 or from age 19 up to 26. By
selecting "yes," you agree to submit all required supporting documentation for your PCR dependent with this
Section D: Signature of Employee/Annuitant
You must sign and date the Affidavit. By signing and dating this section, you are certifying under penalty of perjury
that the information you are providing is true and correct.
Section E: For Employer Use Only
Active Employees: Your employer will complete this section. Retirees: Leave this section blank.
Note to Employer: By completing section E, you are: a.) certifying under penalty of perjury that you are authorized
on behalf of your agency to review this Affidavit and make this eligibility determination, b.) validating that the
submitted documentation meets the requirements based on age, and circumstances of the enrollment, and c.)
ensuring your Human Resources Manager's approval of the enrollment recommendation.
Important Privacy Information
Submission of the requested information is mandatory. The information requested is collected pursuant to the
Government Code (Section 20000 et seq.) and is used for administration of the CalPERS Board's duties under the
Public Employees' Retirement Law, the Social Security Act, and the Public Employees' Medical and Hospital Care
Act, as the case may be. Portions of this information may be transferred to other governmental agencies (such as
your employer), physicians and insurance carriers but only in strict compliance with current statutes regarding
confidentiality. Failure to supply the information may result in CalPERS being unable to perform its functions
regarding your status.
You have the right to review your CalPERS membership file. For questions concerning your rights under the
Information Practices Act of 1977, please contact the CalPERS Customer Contact Center at
888-CalPERS (or 888-225-7377).
Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, State, or local governmental
agency requesting an individual to disclose a Social Security number to inform the individual whether the disclosure is
mandatory or voluntary, by which statutory or other authority such number is solicited, and what uses will be made of
it. Section 111 of Public Law 110-173 requires group health plans to collect and provide member Social Security
numbers for the coordination of federal and State benefits. Furthermore, the CalPERS health program requires each
enrollee's Social Security number for identification purposes and to verify eligibility for benefits.
The CalPERS health program uses Social Security numbers for the following purposes:
1. Enrollee identification for eligibility processing and eligibility verification.
2. Payroll deduction and state contribution for state employees.
3. Billing of contracting agencies for employee and employer contributions.
4. Reports to the CalPERS and other state agencies.
5. Coordination of benefits among health plans.
6. Resolution of member complaints, grievances and appeals with health plans.
HBD-40 (Rev. June 2015)