Fill - Free fillable Get File Group Id 4202574 Filename CalPERS 20 Dependent Verification Affidavit (California Maritime Academy) PDF form

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

• 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

• 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

• 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

ivacy

personal information is of the ut most importance

PERS

The foll

ing informat i

is provided to you in compliance wit h the Informat ion

ctices

t of 1

977

d the

l Pri

Act

of 1974.

fonna

n P

pose

The

info

matio

n requ ested is

ected pur

to the

Gov

ernme

nt Code

(sec

ons

20000

et seq.)

and

will be used

r a

inis

on of B

der

e Reti

rem

ent l

. the

cial

Securi

t, and the Public Employees'

dical

and H

pital

Act

, a s the c

ase

may b

Submission of the reques ted

for

mat

ion is

tor

ure to

com

ply

y result in

Cal

being unable to p

erfo

rm its functions

regarding your status.

Please

clude in

tion that is

not re

est

Social

Num

ber

Social Security numb

ers

a re collected on a

tory and vo

ary basjs, If this is Cal

RS'

first r

uest

r disclosure

your So

al Security

number, th en disclo

re is

dat

ory

. If your

Social Security numb er has already been provided,

discl

osu

re is

luntary. Due to th e use of So

Security num bers by oth er agen

denti

ficati

purposes, we

y b e unable to

verify e

gib

ili

for

ben

efits

w ithout the number.

AcaIPERS

Soc ial Securi

numbers

are

used

r t he

ing purposes:

1. Enro

ee i

den

ificatio

2. Payro

ded

on/s

tate

ntr ib

utio

3. B

ill

ing

ing agenci

oyee/

em ployer

r ib

ions

4 .

orts

lo Cal

RS and other s

te agencies

Coo

rdin ation

benefi

am ong carr iers

6. Resolving

mber appeals, com plai

or gr ieva

th h eal

plan carr iers

Infor

mat

Disclos

ure

Portions of this in

for

maUon

may

be tr ansferr

to other st

ate

agencies

(suc

h as your

er),

icians, and insurance carriers, b

only

str ict accordan

th curre

stat

utes

regarding co

ide

Your Ri

ghts

You have the right to review your m

bership

fil

ained by the

Sys

. For qu

tions

abo

this

, our Privacy

cy, or your r igh

please wr ite

e Cal PE

Priva

Ott

icer

400

Q Street, Sacram ento,

958

11 or

888

CalPERS

888

-22

7377

May

Page 5 of 5

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