Fill - Free fillable Domestic-Partner-Imputed-Income-Declaration - DP 20120120 Financial Responsibility Letter

CITY OF OAKLAND

150 FRANK H. OGAWA PLAZA, 3RD FLOOR • OAKLAND, CALIFORNIA 94612

Department of Human Resources Management (510) 238-3307

FAX

(510) 238-7129

TDD

(510) 839-6451

(continued on back of page)

January 20, 2012

Re: Imputed Income for Domestic Partner and/or

their Dependents Health Coverage

The City of Oakland extends medical, dental and vision benefits coverage to full-time

and permanent part time employees and their registered domestic partners and eligible

dependent child(ren). Our records indicate that you and your Registered Domestic

Partner and/or their dependent child(ren) are enrolled in the City’s sponsored health

plans.

Federal law does not recognize Domestic Partners as dependents unless the employee

contributes over half of the financial support for the individual(s) being covered under the

employee’s benefit plan AND the covered individuals meet the definition of “dependent”

under Code Section 152. Please see the definition of “qualifying relative” on the reverse

side of this notice.

The value of any health coverage an employer pays on behalf of the domestic partner

and/or their dependent(s) who do not meet the definition of “dependent” as define on the

reverse side of this notice must be reported as the imputed income for the employee and

subject to federal income and employment taxes.

The formula used to calculate the imputed income (taxable portion) is as follows:

Example:

Employee plus 3 dependents (domestic partner & 2 dependent children)

Kaiser Family rate = $1,587.14 per month

(fully paid by the City)

To calculate Imputed Income value:

1. $1,587.14 (family rate) divided by 4 (total covered) = $396.79 (premium value for each covered

person)

;

2. $396.79 multiplied by 3 (total number of dependents; cost for employee is excluded)

3. $1,587.14 (total premium) minus $1,190.37 ($396.79 for each 3 dependents)

4. Imputed income value = $1,190.37 per month

The same formula applies for dental and vision coverage paid for by the City.

In some cases benefit contributions toward coverage for the domestic partners and/or

their dependent child(ren) may be exempt from imputed income if the employee can

Imputed Income for Domestic Partner and/or their Dependents Health Coverage

Page 2/2

certify that he/she she resides in the same household and contributes over half of the

dependent(s) financial support during the tax year.

If you meet the exemption criteria for imputed income, please complete the attached

Declaration of Dependency in Support of Non-Taxability of Benefits by February 1, 2012

and return it to the address indicated. If the form is not received by February 1, 2012,

the imputed income value for domestic partner dependent coverage will be applied if

your domestic partner and/or their dependent child(ren) are enrolled in these benefits.

Please mail the form to:

City of Oakland

Department of Human Resource Management

150 Frank Ogawa Plaza, 3rd Floor

Oakland, CA 94612

Attn: DENISE CARTER

Should you have any questions regarding imputed income, please visit the IRS website

at www.irs.gov

, or email Denise Carter at dcarter@oaklandnet.com

Very truly yours,

Yvonne S. Hudson-Harmon

Human Resources Manager, Retirement and Benefits

Enclosure: Declaration of Dependency in Support of Non-Taxability of Benefits

DEPENDENT STATUS

The federal tax code defines a “qualifying relative” as someone with one of the

following relationships to an individual:

1. a child or a descendant of a child

2. a brother, sister, stepbrother or stepsister

3. the father or mother, or an ancestor of either

4. a stepfather or stepmother

5. a son or daughter of a brother or sister of the taxpayer

6. a brother or sister of the father or mother of the taxpayer

7. a son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-

law or sister-in-law

8. an individual (other than an individual who at any time during the taxable

year was the spouse of the taxpayer) who, for the taxable year of the

taxpayer, has the same principal resident as the taxpayer and is a

member of the taxpayer’s household.

CITY OF OAKLAND

150 FRANK H.OGAWA PLAZA, 3RD FLOOR • OAKLAND, CALIFORNIA 94612-2021

Department of Human Resources Management (510) 238-3307

FAX

(510) 238-7129

TDD

(510) 839-6451

DeclarationofDependencyinSupportofNon‐TaxabilityofBenefits



I, declarethat:

A. MySocialSecurityNumberis

,

B. IamrequestingtheCityofOaklandprovideinsurancecoverage(medicaland/ordentaland/orvision)formyselfandthefollowing

person(s)(ifmorespaceneeded,listadditionalperson(s)onasecondpage):



Name(Last,First,MI)BirthDateSex

Relationship

(indicate on of the following: domestic

partner, natural child of employee,

child of domestic partner,

economically dependant child,

mentally or physically disabled child.)

1.



2.



3.



4.



C. Ihaveverifiedthateachoftheabovenamedperson(s)indeclaration#Bisentitledtobeclaimedasadependentonmyannualfederal

incometaxreturn.

D. Eachoftheabovenamedperson(s)indeclaration#Bresideswithmeasamemberofmyhousehold.

E. Iam

responsibleforfiftypercent(50%)ormoreofthefinancialsupportandmaintenanceforeachoftheabovenamedperson(s)in

declaration#B.

F. IunderstandthatIamresponsibleforthetaxconsequences(includinginterestandpenalties)shouldtherebeanymisstatementsmade

inthisdeclarationor,evenin

theabsenceofamisstatement,shouldtheUnitedStatesInternalRevenueServiceortheStateofCalifornia

FranchiseTaxBoardsodeterminethatthebenefitsIamreceivingininsurancecoverageformyselfand/ortheperson(s)listedabovein

declaration#Bareotherwisetaxableincome.

G. IwillnotifytheCityofOaklandBenefitsOfficeinwritingwithinthirty(30)daysofanychangerelatedtothedependentstatusofanyof

theabovenamedindividualsindeclaration#B.

H. IagreetoprovideanysupportingdocumentationwhenrequestedbytheBenefitsofficesolongas Ihavemydomesticpartner

oreligible

dependentsenrolledinoneormoreoftheCityofOakland’sinsuranceplans.

Ideclare,underpenaltyofperjury,thattheforegoingdeclarationsaretrueandcorrect.

Executedthis dayof intheYear at ,California.







 EmployeeSignature



CLEARLYPrintEmployeeName(Last,First,MI)

PrintLAST4DIGITS

ofEmployeeSocialSecurity

Day Month Year City,Town

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