Health Account Management Division
P.O. BOX 942715, Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | TTY (877) 249-7442
FAX (800) 959-6545 | www.calpers.ca.gov
Affidavit of Parent-Child Relationship
The Public Employees' Medical and Hospital Care Act (PEMHCA), allows employees and annuitants to enroll family
members in the CalPERS Health Benefits Program. Pursuant to Title 2, California Code of Regulations, 599.500(o), a
"parent-child relationship" (PCR) is established when you intentionally assume parental status or duties over a child
who is not your adopted, step, or recognized natural child, and meet specific enrollment criteria.
As specified in Section 599.500(o) and outlined below, you are required to substantiate a financial responsibility upon
initial enrollment and annually thereafter, up to the child reaching age 26. You must submit a separate PCR Affidavit
for each PCR dependent.
Note: Spouses of your adopted, step, and recognized natural children do not qualify for CalPERS health coverage
under any circumstances.
SECTION A: Employee/Annuitant Information
1. Name (First)
(M.I.)
(Last)
2. Social Security Number
- -
3. Date of Birth
(mm/dd/yyyy)
//
4. Date you assumed the primary parental status or duties for the PCR dependent:
/ /
(mm/dd/yyyy)
5. Relationship to the PCR dependent:
SECTION B: PCR Dependent Information
(Last)
(M.I.)
6. Name (First)
--
7. Social Security Number
//
8. Date of Birth
(mm/dd/yyyy)
9. Address (if different from yours): (Street)
(City) (State) (ZIP)
SECTION C: Supporting Documentation Requirements
10. As evidenced by your selection below, you are certifying you have assumed parental status or duties and will
provide the required supporting documentation for your PCR dependent with this Affidavit.
For a PCR Dependent Under Age 19:
A copy of the first page of your income tax return from the previous tax year listing the child as a
tax dependent.
In lieu of a tax return, for a time not to exceed one tax filing year, you may submit other
documents that substantiate the child's financial dependence upon you, including, but not limited
to: current legal judgments/court documents showing the subscriber's legal parental status or
duties/guardianship over the child; bank, credit card, tuition or insurance statements/payments;
school records; bills or mail indicating common residency with the dependent (collectively referred
to as "Other Suitable PCR Documentation").
Yes
No
For a PCR Dependent From Age 19 Up to Age 26:
A copy of the first page of your income tax return from the previous tax year listing the child as a
tax dependent, OR
Other Suitable PCR Documentation, as mentioned above, that substantiates that the child is
financially dependent upon you provided that the child:
o Either lives with you for more than 50 percent of the time, or is a full-time student, AND
o Is dependent upon you for more than 50 percent of the child's support
Yes
No
HBD-40 (Rev. June 2015)
_________________________________
_________________________________
SECTION D: Signature of Employee/Annuitant
11. I recognize this affidavit is a legally binding document. I accept full responsibility to notify my employer or
CalPERS of any changes pertaining to this PCR. I further understand the provision of California Government
Code 20085, which states in part:
(a) It is unlawful for a person to do any of the following:
(1) Make, or cause to be made, any knowingly false material statement or material representation, to
knowingly fail to disclose a material fact, or to otherwise provide false information with the intent to use it,
or allow it to be used, to obtain, receive, continue, increase, deny or reduce any benefit administered by
this system.
(2) Present, or cause to be presented, any knowingly false material statement or material representation for
the purpose of supporting or opposing an application for any benefit administered by this system.
I hereby certify under penalty of perjury, that the information I have provided is true and correct to the best of
my knowledge. I also agree to provide all supporting documentation requested by my employer or CalPERS. I
understand that each PCR dependent must be certified upon initial enrollment and annually thereafter up to age 26. I
also understand that certification includes submission of this Affidavit and the required supporting documents.
Employee/Annuitant Signature Date
Important!
Active Employees: Return this Affidavit and the required supporting documents to your employer.
Retirees: Return this Affidavit and the required supporting documents to CalPERS.
SECTION E: For Employer Use Only
12. I hereby certify under penalty of perjury as follows: That I am a duly appointed, qualified, and acting officer
of the following agency:
I have reviewed the above affidavit and verified the identity of the employee or annuitant submitting this affidavit.
I recommend enrolling/re-certifying this PCR dependent based on the information provided and attached
documentation [per CCR §599.500(o)].
I do not recommend enrolling/re-certifying this PCR dependent based on the information provided and/or lack of
supporting documentation [per CCR §599.500(o)].
Enroll Recertify Do not enroll
Human Resources Manager Name (Print)
Health Benefits Officer Name (Print)
Do not recertify
_______________________________ ______________
Human Resources Manager Signature Date
_______________________________ ______________
Health Benefits Officer Signature Date
HBD-40 (Rev. June 2015)
Affidavit of Parent-Child Relationship Instructions
S
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
Affidavit.
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)
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
The information requested is collected pursuant
to the Government Code (sections
20000 et seq.)
and will be used for administration of Board
duties under the Retirement Law, the Social
Security Act, and the Public Employees’ Medical
and Hospital Care Act, as 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 information that is
not requested.
Social Security Numbers
Social Security numbers are collected on a
mandatory and voluntary basis. 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 numbers by other agencies for
identification purposes, we may be unable to
verify eligibility for benefits without the number.
Social Security numbers are used for the
following purposes:
1. Enrollee identification
2. Payroll deduction/state contributions
3. Billing of contracting agencies for employee/
employer contributions
4. Reports to CalPERS and other state agencies
5. Coordination of benefits among carriers
6. Resolving member appeals, complaints,
or grievances with health plan carriers
Information Disclosure
Portions of this information may be transferred
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
in strict accordance with current statutes
regarding confidentiality.
Your Rights
You have the right to review your membership
files maintained by the System. For questions
about this notice, our Privacy Policy, or your rights,
please write to the CalPERS Privacy Ocer at
400 Q Street, Sacramento, CA 95811 or call us
at 888 CalPERS (or 888-225-7377).
May 2016
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