Fillable Dependent-verification-affidavit Dependent Verification Affidavit

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Dependent-verification-affidavit Dependent Verification Affidavit

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CalPERS
P.O. Box 942715 Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | Fax: (800) 959-6545
www.calpers.ca.gov
California Public Employees' Retirement System
Dependent Verification Affidavit
At least once every three years, California Government Code Section 22843.1 requires your
Employer to verify the eligibility of your dependent(s). This Affidavit is required to be completed by
the Subscriber.
Important!
Active Employees: Return this Affidavit and the required supporting documents to your agency’s
personnel office.
Retirees: Return this Affidavit and the required supporting documents to CalPERS.
SECTION A: Subscriber Information
Subscriber Name: ____________________________________________________________
Subscriber CalPERS ID/SSN: _______________________________ ___________________
SECTION B: Dependent(s) Requiring Verification
List all your dependents required to be verified.
Dependent Name Relationship Date of Birth
Page 1 of 5
Relationship Type Acceptable Verification Documents
Spouse A copy of your marriage certificate AND one of the following
documents:
• A copy of the front page of the most recent federal or
state tax return confirming dependent as your spouse
OR
• A copy of a document dated within the last 60 days
showing current relationship status, such as a recurring
household bill or joint statement of account. The
document must list your name, the name of your spouse,
and your address.
Registered Domestic Partner
A copy of your Declaration of Domestic Partnership registered
with the California Secretary of State AND one of the following
documents:
• A copy of the front page of the most recent federal or
state tax return confirming dependent as your domestic
partner
OR
• A copy of a document dated within the last 60 days
showing current relationship status, such as a recurring
household bill or joint statement of account. The
document must list your name, the name of your partner,
and your address.
Children (natural-born, adopted,
placement for adoption, step, or
registered domestic partner’s
children) up to age 26 (the
month in which dependent
attains age 26)*
• A copy of the child’s birth certificate or adoption
certificate naming you, your spouse, or your domestic
partner as the parent of the child
OR
• A copy of the court order naming you, your spouse, or
your domestic partner as the legal guardian of the child.
* For a stepchild, or domestic partners child, you must also
provide documentation of your current relationship to your
spouse or domestic partner as requested above.
SECTION C: Required and Acceptable Verification Documents
Review the table below to assist with the required and acceptable documentation needed to verify
each dependent’s eligibility. All required documents MUST include a date, your name, and the
name of the dependent being verified.
Page 2 of 5
SECTION D: Initial and Signature of Subscriber
Every statement within this section below must be initialed by the Subscriber. The Subscriber
must sign and date.
I hereby certify under penalty of perjury:
_____ I understand the eligibility requirements described in this document and that all information
provided by me is true and correct to the best of my knowledge.
_____ I provided the required documentation to substantiate the relationship of my enrolled
dependent(s).
_____ I understand that additional information and supporting documentation may be requested
as necessary to substantiate dependent eligibility for health or dental benefits.
_____ I agree to notify CalPERS/ my employer in writing within 60 days upon the dissolution of a
marriage, domestic partnership, or when a change in a dependent’s eligibility occurs.
_____ I agree that I am responsible for ensuring that my health enrollment information for myself
and my family members is accurate. If I do not maintain accurate health enrollment
information, I may be liable for reimbursement of health premiums or health care services
incurred during the ineligibility period.
Subscriber Name:_____________________ Subscriber CalPERS ID: _______________
Subscriber Signature: _______________________________ Date: ________________
Page 3 of 5
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SECTION E: Employer Authorization
For Employer Use Only
This section must be initialed, signed, and dated by the personnel office’s Human Resources
Representative.
I hereby certify that:
______ I am a duly appointed and qualified representative of the agency/department.
______ I have reviewed the employee’s supporting documents to verify each dependent‘s
eligibility.
______ I informed the employee they are required to notify their employer in writing within 60 days
upon the dissolution of a marriage or termination of domestic partnership, when a parent-
child relationship ceases, or a change in a dependent‘s eligibility occurs.
______ I informed the employee they may be required to reimburse their employer, the health,
dental, or vision benefit plan, and CalPERS for expenditures made for medical claims, or
health premiums incurred during the ineligibility period of any family member if any of the
submitted documentation is found to be inaccurate or fraudulent and that a review of
eligibility can occur at any time.
______ I retained copies of the employee’s health, dental, and vision enrollment form(s) and all
supporting documents to verify eligibility of employees’ dependent(s) in the employee’s
Official Personnel File.
______ I will provide a copy of this completed affidavit to the employee.
______ Based on the information provided and review of the documentation, I am approving the
enrollment of such dependent(s).
HR Representative Name: _________________________ Job Title:___________________
HR Representative Signature: _______________________ Date:___________________
Page 4 of 5
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ivacy Notice
The
pr
ivacy
of
personal information is of the ut most importance
to
Ca
l
PERS
.
The foll
ow
ing informat i
on
is provided to you in compliance wit h the Informat ion
P
ra
ctices
Ac
t of 1
977
an
d the
Fe
de
ra
l Pri
va
cy
Act
of 1974.
ln
fonna
t
io
n P
ur
pose
The
info
r
matio
n requ ested is
co
ll
ected pur
su
a
nt
to the
Gov
ernme
nt Code
(sec
ti
ons
20000
et seq.)
and
will be used
fo
r a
dm
inis
tr
a
ti
on of B
oa
rd
d
ut
i
es
un
der
th
e Reti
rem
ent l
aw
. the
So
cial
Securi
ty
Ac
t, and the Public Employees'
Me
dical
and H
os
pital
Ca
re
Act
, a s the c
ase
may b
e.
Submission of the reques ted
in
for
mat
ion is
ma
n
da
tor
y.
Fa
il
ure to
com
ply
ma
y result in
Cal
PE
RS
being unable to p
erfo
rm its functions
regarding your status.
Please
do
no
t
in
clude in
fo
r
ma
tion that is
not re
qu
est
ed
.
Social
Se
cu
ri
ty
Num
ber
s
Social Security numb
ers
a re collected on a
ma
n
da
tory and vo
lu
nt
ary basjs, If this is Cal
PE
RS'
first r
eq
uest
fo
r disclosure
of
your So
ci
al Security
number, th en disclo
su
re is
ma
n
dat
ory
. If your
Social Security numb er has already been provided,
discl
osu
re is
vo
luntary. Due to th e use of So
ci
al
Security num bers by oth er agen
ci
es
fo
r
i
denti
ficati
on
purposes, we
ma
y b e unable to
verify e
li
gib
ili
ty
for
ben
efits
w ithout the number.
AcaIPERS
Soc ial Securi
ty
numbers
are
used
fo
r t he
fo
ll
ow
ing purposes:
1. Enro
ll
ee i
den
t
ificatio
n
2. Payro
ll
ded
u
ct
i
on/s
tate
co
ntr ib
utio
ns
3. B
ill
ing
of
co
nt
ra
ct
ing agenci
es
fo
r
em
pl
oyee/
em ployer
co
nt
r ib
ut
ions
4 .
Re
p
orts
lo Cal
PE
RS and other s
la
te agencies
5.
Coo
rdin ation
of
benefi
ts
am ong carr iers
6. Resolving
me
mber appeals, com plai
nt
s,
or gr ieva
nc
es
wi
th h eal
th
plan carr iers
Infor
mat
i
on
Disclos
ure
Portions of this in
for
maUon
may
be tr ansferr
ed
to other st
ate
agencies
(suc
h as your
em
pl
oy
er),
ph
ys
icians, and insurance carriers, b
ut
only
in
str ict accordan
ce
wi
th curre
nt
stat
utes
regarding co
nf
ide
nt
ia
li
t
y.
Your Ri
ghts
You have the right to review your m
em
bership
fil
es
ma
i
nt
ained by the
Sys
t
em
. For qu
es
tions
abo
ut
this
no
ti
ce
, our Privacy
Po
li
cy, or your r igh
ts
,
please wr ite
to
th
e Cal PE
RS
Priva
cy
Ott
icer
at
400
Q Street, Sacram ento,
CA
958
11 or
ca
ll
us
at
888
CalPERS
(o
r
888
-22
5-
7377
).
May
20
16
Page 5 of 5
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Completed 16 February 2020

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